therapeutic hypothermia - american heart associationwcm/@mwa/...introduction each year more than 300...
TRANSCRIPT
THERAPEUTIC
HYPOTHERMIA
John Stroger Hospital of Cook County
Director Medical Intensive Care Unit
Chairman Resus Committee
Director of Critical Care Ultrasound
Assistant Professor of Medicine
Rush University Medical College
Conflict of interest none
COOL THE BRAIN
AND KEEP COOL
Objectives
bull Understand obstacles to start a TH program
bull Review of literature for given reason why TH is not done
bull How to start a TH program
CLINICAL CASECase
53 year old male with pmh of HTN and heroin use presented to ED co nausea and vomiting
with possible bloody emesis dark tarry stools and diaphoresis
One hour after arrival the patient was found unresponsive and pulseless and Ventricular
fibrillation CPR was initiated immediately Patient converted to sinus tachycardia after the
second delivered shock The patient remained unresponsive
VS BP 150108 HR 75 RR 19 Temp 984 SaO2 98 on FiO2 100
Neurologic unresponsive GCS 5
Resp intubated and on MV
GU foley with a temperature monitor
Post cardiac arrest therapeutic hypothermia was initiated with initial infusion of 4⁰ C iv fluids
The patient was than transferred to the MICU where the TH protocol with target core body
temperature of 33 ⁰ C using external cooling with body wraps was continued
Clinic course
Patient on TH protocol for 24 hours and than passively
rewarmed
Upon reaching normothermia all sedation were stopped
His course was complicated by ARDS likely due to
VAPAspiration pneumonitis
Extubated on day 8
He underwent coronary angiogram for abnormal EKG with QT
prolongation Angiogram was normal
Patient eventually discharge on hospital day 15
Patient was seen in medicine clinic 2 weeks after event
Complete neurologic recovery
INTRODUCTION Each year more than 300 000 sudden cardiac arrests occur in the
United States alone (12)
Despite advances in care and technology outcome remains
poor
Less than 25 of in-hospital and less than 11 of out of hospital
cardiac arrest survive to discharge or are alive at 30 days (2-7)
Functional status post cardiac arrest is generally poor with less
than 25 of surviving patients being discharged with good neurologic function (8-11)
The recognition of the persistence of unfavorable neurologic
outcomes has led to numerous studies trying to improve the
neurologic recovery of these patients
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC
Post SCA Hospital Care
Admit to ICU
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Cell death
HYPOTHERMIA TRIALS
Animals study have shown that induction of mild (33-36⁰C) to moderate (27-33⁰C) hypothermia mitigates and can prevent postischemic brain damage after cardiopulmonary arrest (12-14)
In 1997 Bernard et al and in 1998 Yanagawa et al showed improved outcome with TH in patients after SCA (15 16)
This lead to two larger trials The results of both were published in 2002 in the NEJM (17 18)
Based on these and other trials the AHA and ILCOR make a strong recommendation for TH for patients suffering at out of hospital SCA with a shockable rhythm (19-21)
The AHA also strongly recommends TH for patient suffering a non-shockable SCA and in-hospital SCA independent of rhythm The ILCOR makes a weaker recommendation for TH in these patients (19-22)
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
Conflict of interest none
COOL THE BRAIN
AND KEEP COOL
Objectives
bull Understand obstacles to start a TH program
bull Review of literature for given reason why TH is not done
bull How to start a TH program
CLINICAL CASECase
53 year old male with pmh of HTN and heroin use presented to ED co nausea and vomiting
with possible bloody emesis dark tarry stools and diaphoresis
One hour after arrival the patient was found unresponsive and pulseless and Ventricular
fibrillation CPR was initiated immediately Patient converted to sinus tachycardia after the
second delivered shock The patient remained unresponsive
VS BP 150108 HR 75 RR 19 Temp 984 SaO2 98 on FiO2 100
Neurologic unresponsive GCS 5
Resp intubated and on MV
GU foley with a temperature monitor
Post cardiac arrest therapeutic hypothermia was initiated with initial infusion of 4⁰ C iv fluids
The patient was than transferred to the MICU where the TH protocol with target core body
temperature of 33 ⁰ C using external cooling with body wraps was continued
Clinic course
Patient on TH protocol for 24 hours and than passively
rewarmed
Upon reaching normothermia all sedation were stopped
His course was complicated by ARDS likely due to
VAPAspiration pneumonitis
Extubated on day 8
He underwent coronary angiogram for abnormal EKG with QT
prolongation Angiogram was normal
Patient eventually discharge on hospital day 15
Patient was seen in medicine clinic 2 weeks after event
Complete neurologic recovery
INTRODUCTION Each year more than 300 000 sudden cardiac arrests occur in the
United States alone (12)
Despite advances in care and technology outcome remains
poor
Less than 25 of in-hospital and less than 11 of out of hospital
cardiac arrest survive to discharge or are alive at 30 days (2-7)
Functional status post cardiac arrest is generally poor with less
than 25 of surviving patients being discharged with good neurologic function (8-11)
The recognition of the persistence of unfavorable neurologic
outcomes has led to numerous studies trying to improve the
neurologic recovery of these patients
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC
Post SCA Hospital Care
Admit to ICU
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Cell death
HYPOTHERMIA TRIALS
Animals study have shown that induction of mild (33-36⁰C) to moderate (27-33⁰C) hypothermia mitigates and can prevent postischemic brain damage after cardiopulmonary arrest (12-14)
In 1997 Bernard et al and in 1998 Yanagawa et al showed improved outcome with TH in patients after SCA (15 16)
This lead to two larger trials The results of both were published in 2002 in the NEJM (17 18)
Based on these and other trials the AHA and ILCOR make a strong recommendation for TH for patients suffering at out of hospital SCA with a shockable rhythm (19-21)
The AHA also strongly recommends TH for patient suffering a non-shockable SCA and in-hospital SCA independent of rhythm The ILCOR makes a weaker recommendation for TH in these patients (19-22)
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
COOL THE BRAIN
AND KEEP COOL
Objectives
bull Understand obstacles to start a TH program
bull Review of literature for given reason why TH is not done
bull How to start a TH program
CLINICAL CASECase
53 year old male with pmh of HTN and heroin use presented to ED co nausea and vomiting
with possible bloody emesis dark tarry stools and diaphoresis
One hour after arrival the patient was found unresponsive and pulseless and Ventricular
fibrillation CPR was initiated immediately Patient converted to sinus tachycardia after the
second delivered shock The patient remained unresponsive
VS BP 150108 HR 75 RR 19 Temp 984 SaO2 98 on FiO2 100
Neurologic unresponsive GCS 5
Resp intubated and on MV
GU foley with a temperature monitor
Post cardiac arrest therapeutic hypothermia was initiated with initial infusion of 4⁰ C iv fluids
The patient was than transferred to the MICU where the TH protocol with target core body
temperature of 33 ⁰ C using external cooling with body wraps was continued
Clinic course
Patient on TH protocol for 24 hours and than passively
rewarmed
Upon reaching normothermia all sedation were stopped
His course was complicated by ARDS likely due to
VAPAspiration pneumonitis
Extubated on day 8
He underwent coronary angiogram for abnormal EKG with QT
prolongation Angiogram was normal
Patient eventually discharge on hospital day 15
Patient was seen in medicine clinic 2 weeks after event
Complete neurologic recovery
INTRODUCTION Each year more than 300 000 sudden cardiac arrests occur in the
United States alone (12)
Despite advances in care and technology outcome remains
poor
Less than 25 of in-hospital and less than 11 of out of hospital
cardiac arrest survive to discharge or are alive at 30 days (2-7)
Functional status post cardiac arrest is generally poor with less
than 25 of surviving patients being discharged with good neurologic function (8-11)
The recognition of the persistence of unfavorable neurologic
outcomes has led to numerous studies trying to improve the
neurologic recovery of these patients
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC
Post SCA Hospital Care
Admit to ICU
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Cell death
HYPOTHERMIA TRIALS
Animals study have shown that induction of mild (33-36⁰C) to moderate (27-33⁰C) hypothermia mitigates and can prevent postischemic brain damage after cardiopulmonary arrest (12-14)
In 1997 Bernard et al and in 1998 Yanagawa et al showed improved outcome with TH in patients after SCA (15 16)
This lead to two larger trials The results of both were published in 2002 in the NEJM (17 18)
Based on these and other trials the AHA and ILCOR make a strong recommendation for TH for patients suffering at out of hospital SCA with a shockable rhythm (19-21)
The AHA also strongly recommends TH for patient suffering a non-shockable SCA and in-hospital SCA independent of rhythm The ILCOR makes a weaker recommendation for TH in these patients (19-22)
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
Objectives
bull Understand obstacles to start a TH program
bull Review of literature for given reason why TH is not done
bull How to start a TH program
CLINICAL CASECase
53 year old male with pmh of HTN and heroin use presented to ED co nausea and vomiting
with possible bloody emesis dark tarry stools and diaphoresis
One hour after arrival the patient was found unresponsive and pulseless and Ventricular
fibrillation CPR was initiated immediately Patient converted to sinus tachycardia after the
second delivered shock The patient remained unresponsive
VS BP 150108 HR 75 RR 19 Temp 984 SaO2 98 on FiO2 100
Neurologic unresponsive GCS 5
Resp intubated and on MV
GU foley with a temperature monitor
Post cardiac arrest therapeutic hypothermia was initiated with initial infusion of 4⁰ C iv fluids
The patient was than transferred to the MICU where the TH protocol with target core body
temperature of 33 ⁰ C using external cooling with body wraps was continued
Clinic course
Patient on TH protocol for 24 hours and than passively
rewarmed
Upon reaching normothermia all sedation were stopped
His course was complicated by ARDS likely due to
VAPAspiration pneumonitis
Extubated on day 8
He underwent coronary angiogram for abnormal EKG with QT
prolongation Angiogram was normal
Patient eventually discharge on hospital day 15
Patient was seen in medicine clinic 2 weeks after event
Complete neurologic recovery
INTRODUCTION Each year more than 300 000 sudden cardiac arrests occur in the
United States alone (12)
Despite advances in care and technology outcome remains
poor
Less than 25 of in-hospital and less than 11 of out of hospital
cardiac arrest survive to discharge or are alive at 30 days (2-7)
Functional status post cardiac arrest is generally poor with less
than 25 of surviving patients being discharged with good neurologic function (8-11)
The recognition of the persistence of unfavorable neurologic
outcomes has led to numerous studies trying to improve the
neurologic recovery of these patients
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC
Post SCA Hospital Care
Admit to ICU
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Cell death
HYPOTHERMIA TRIALS
Animals study have shown that induction of mild (33-36⁰C) to moderate (27-33⁰C) hypothermia mitigates and can prevent postischemic brain damage after cardiopulmonary arrest (12-14)
In 1997 Bernard et al and in 1998 Yanagawa et al showed improved outcome with TH in patients after SCA (15 16)
This lead to two larger trials The results of both were published in 2002 in the NEJM (17 18)
Based on these and other trials the AHA and ILCOR make a strong recommendation for TH for patients suffering at out of hospital SCA with a shockable rhythm (19-21)
The AHA also strongly recommends TH for patient suffering a non-shockable SCA and in-hospital SCA independent of rhythm The ILCOR makes a weaker recommendation for TH in these patients (19-22)
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
CLINICAL CASECase
53 year old male with pmh of HTN and heroin use presented to ED co nausea and vomiting
with possible bloody emesis dark tarry stools and diaphoresis
One hour after arrival the patient was found unresponsive and pulseless and Ventricular
fibrillation CPR was initiated immediately Patient converted to sinus tachycardia after the
second delivered shock The patient remained unresponsive
VS BP 150108 HR 75 RR 19 Temp 984 SaO2 98 on FiO2 100
Neurologic unresponsive GCS 5
Resp intubated and on MV
GU foley with a temperature monitor
Post cardiac arrest therapeutic hypothermia was initiated with initial infusion of 4⁰ C iv fluids
The patient was than transferred to the MICU where the TH protocol with target core body
temperature of 33 ⁰ C using external cooling with body wraps was continued
Clinic course
Patient on TH protocol for 24 hours and than passively
rewarmed
Upon reaching normothermia all sedation were stopped
His course was complicated by ARDS likely due to
VAPAspiration pneumonitis
Extubated on day 8
He underwent coronary angiogram for abnormal EKG with QT
prolongation Angiogram was normal
Patient eventually discharge on hospital day 15
Patient was seen in medicine clinic 2 weeks after event
Complete neurologic recovery
INTRODUCTION Each year more than 300 000 sudden cardiac arrests occur in the
United States alone (12)
Despite advances in care and technology outcome remains
poor
Less than 25 of in-hospital and less than 11 of out of hospital
cardiac arrest survive to discharge or are alive at 30 days (2-7)
Functional status post cardiac arrest is generally poor with less
than 25 of surviving patients being discharged with good neurologic function (8-11)
The recognition of the persistence of unfavorable neurologic
outcomes has led to numerous studies trying to improve the
neurologic recovery of these patients
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC
Post SCA Hospital Care
Admit to ICU
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Cell death
HYPOTHERMIA TRIALS
Animals study have shown that induction of mild (33-36⁰C) to moderate (27-33⁰C) hypothermia mitigates and can prevent postischemic brain damage after cardiopulmonary arrest (12-14)
In 1997 Bernard et al and in 1998 Yanagawa et al showed improved outcome with TH in patients after SCA (15 16)
This lead to two larger trials The results of both were published in 2002 in the NEJM (17 18)
Based on these and other trials the AHA and ILCOR make a strong recommendation for TH for patients suffering at out of hospital SCA with a shockable rhythm (19-21)
The AHA also strongly recommends TH for patient suffering a non-shockable SCA and in-hospital SCA independent of rhythm The ILCOR makes a weaker recommendation for TH in these patients (19-22)
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
Clinic course
Patient on TH protocol for 24 hours and than passively
rewarmed
Upon reaching normothermia all sedation were stopped
His course was complicated by ARDS likely due to
VAPAspiration pneumonitis
Extubated on day 8
He underwent coronary angiogram for abnormal EKG with QT
prolongation Angiogram was normal
Patient eventually discharge on hospital day 15
Patient was seen in medicine clinic 2 weeks after event
Complete neurologic recovery
INTRODUCTION Each year more than 300 000 sudden cardiac arrests occur in the
United States alone (12)
Despite advances in care and technology outcome remains
poor
Less than 25 of in-hospital and less than 11 of out of hospital
cardiac arrest survive to discharge or are alive at 30 days (2-7)
Functional status post cardiac arrest is generally poor with less
than 25 of surviving patients being discharged with good neurologic function (8-11)
The recognition of the persistence of unfavorable neurologic
outcomes has led to numerous studies trying to improve the
neurologic recovery of these patients
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC
Post SCA Hospital Care
Admit to ICU
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Cell death
HYPOTHERMIA TRIALS
Animals study have shown that induction of mild (33-36⁰C) to moderate (27-33⁰C) hypothermia mitigates and can prevent postischemic brain damage after cardiopulmonary arrest (12-14)
In 1997 Bernard et al and in 1998 Yanagawa et al showed improved outcome with TH in patients after SCA (15 16)
This lead to two larger trials The results of both were published in 2002 in the NEJM (17 18)
Based on these and other trials the AHA and ILCOR make a strong recommendation for TH for patients suffering at out of hospital SCA with a shockable rhythm (19-21)
The AHA also strongly recommends TH for patient suffering a non-shockable SCA and in-hospital SCA independent of rhythm The ILCOR makes a weaker recommendation for TH in these patients (19-22)
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
INTRODUCTION Each year more than 300 000 sudden cardiac arrests occur in the
United States alone (12)
Despite advances in care and technology outcome remains
poor
Less than 25 of in-hospital and less than 11 of out of hospital
cardiac arrest survive to discharge or are alive at 30 days (2-7)
Functional status post cardiac arrest is generally poor with less
than 25 of surviving patients being discharged with good neurologic function (8-11)
The recognition of the persistence of unfavorable neurologic
outcomes has led to numerous studies trying to improve the
neurologic recovery of these patients
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC
Post SCA Hospital Care
Admit to ICU
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Cell death
HYPOTHERMIA TRIALS
Animals study have shown that induction of mild (33-36⁰C) to moderate (27-33⁰C) hypothermia mitigates and can prevent postischemic brain damage after cardiopulmonary arrest (12-14)
In 1997 Bernard et al and in 1998 Yanagawa et al showed improved outcome with TH in patients after SCA (15 16)
This lead to two larger trials The results of both were published in 2002 in the NEJM (17 18)
Based on these and other trials the AHA and ILCOR make a strong recommendation for TH for patients suffering at out of hospital SCA with a shockable rhythm (19-21)
The AHA also strongly recommends TH for patient suffering a non-shockable SCA and in-hospital SCA independent of rhythm The ILCOR makes a weaker recommendation for TH in these patients (19-22)
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
The recognition of the persistence of unfavorable neurologic
outcomes has led to numerous studies trying to improve the
neurologic recovery of these patients
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC
Post SCA Hospital Care
Admit to ICU
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Cell death
HYPOTHERMIA TRIALS
Animals study have shown that induction of mild (33-36⁰C) to moderate (27-33⁰C) hypothermia mitigates and can prevent postischemic brain damage after cardiopulmonary arrest (12-14)
In 1997 Bernard et al and in 1998 Yanagawa et al showed improved outcome with TH in patients after SCA (15 16)
This lead to two larger trials The results of both were published in 2002 in the NEJM (17 18)
Based on these and other trials the AHA and ILCOR make a strong recommendation for TH for patients suffering at out of hospital SCA with a shockable rhythm (19-21)
The AHA also strongly recommends TH for patient suffering a non-shockable SCA and in-hospital SCA independent of rhythm The ILCOR makes a weaker recommendation for TH in these patients (19-22)
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC
Post SCA Hospital Care
Admit to ICU
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Cell death
HYPOTHERMIA TRIALS
Animals study have shown that induction of mild (33-36⁰C) to moderate (27-33⁰C) hypothermia mitigates and can prevent postischemic brain damage after cardiopulmonary arrest (12-14)
In 1997 Bernard et al and in 1998 Yanagawa et al showed improved outcome with TH in patients after SCA (15 16)
This lead to two larger trials The results of both were published in 2002 in the NEJM (17 18)
Based on these and other trials the AHA and ILCOR make a strong recommendation for TH for patients suffering at out of hospital SCA with a shockable rhythm (19-21)
The AHA also strongly recommends TH for patient suffering a non-shockable SCA and in-hospital SCA independent of rhythm The ILCOR makes a weaker recommendation for TH in these patients (19-22)
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Cell death
HYPOTHERMIA TRIALS
Animals study have shown that induction of mild (33-36⁰C) to moderate (27-33⁰C) hypothermia mitigates and can prevent postischemic brain damage after cardiopulmonary arrest (12-14)
In 1997 Bernard et al and in 1998 Yanagawa et al showed improved outcome with TH in patients after SCA (15 16)
This lead to two larger trials The results of both were published in 2002 in the NEJM (17 18)
Based on these and other trials the AHA and ILCOR make a strong recommendation for TH for patients suffering at out of hospital SCA with a shockable rhythm (19-21)
The AHA also strongly recommends TH for patient suffering a non-shockable SCA and in-hospital SCA independent of rhythm The ILCOR makes a weaker recommendation for TH in these patients (19-22)
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
HYPOTHERMIA TRIALS
Animals study have shown that induction of mild (33-36⁰C) to moderate (27-33⁰C) hypothermia mitigates and can prevent postischemic brain damage after cardiopulmonary arrest (12-14)
In 1997 Bernard et al and in 1998 Yanagawa et al showed improved outcome with TH in patients after SCA (15 16)
This lead to two larger trials The results of both were published in 2002 in the NEJM (17 18)
Based on these and other trials the AHA and ILCOR make a strong recommendation for TH for patients suffering at out of hospital SCA with a shockable rhythm (19-21)
The AHA also strongly recommends TH for patient suffering a non-shockable SCA and in-hospital SCA independent of rhythm The ILCOR makes a weaker recommendation for TH in these patients (19-22)
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
PHASES OF SCA
Cardiac arrestCPRACLS
Death
ROSC Resuscitate TH
No recovery
Recovery
Post CA Hospital Care
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
PATHOPHYSIOLOGY OF BRAIN INJURY
FOLLOWING SCA
SCA
Decreased brain perfusion
Brain tissue Hypoxia
Decreased ATP production
Anaerobic metabolism
Ca into cell
Release of
neuroexcitatory
transmitters Cerebral
Inflammation
Free radical
production Disruption of BBB
damage to
endoth
Prevent Cell
death
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
Despite the proven benefit of TH especially for out-of-hospital
VTVF SCA
and
AHA and ICLOR recommendations
Less than 75 of hospitals
in the US have a TH program in place
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
REASON TO FORGO A TH PROGRAM
High cost
Reservation about effectiveness
Unclear if beneficial for non-shockable rhythm
Poor outcome of in-hospital SCA patients
Low numbers of out-of-hospital SCA
Optimal target temperature
Optimal cooling device
Lack of awareness
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
COST
Can we talk about cost when we can improve the outcome of a
patient who has a chance for full recovery
What would you want if it were you
Cost of TH
Cooling devices prices differ and also depend on buying power of
facility and negotiation
Staffing 11 nursing for the initiation (6-8 hours) and cooling phase (up
to 16 hours) as well as rewarming phase (12 hours)
Prolonged Hospital stay Prognosis should only be done 72-96 hours
after patient regained normothermia
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
RESERVATION ABOUT EFFECTIVENESS1 Out-of-hospital SCA
1 Shockable rhythm
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
6851
p =
0145
49 26 p =
0046
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
2 Out-of-hospital ndash non Shockable rhythm
Non shockable rhythm ndash no clear evidence for either benefit or harm
23-25
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
In-hospital SCA independent of rhythm - possible harm
26-28
2 In-hospital SCA independent of rhythm
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
COOLING METHODS
INVASIVENON-INVASIVE
(EXTERNAL)
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
Cold water mattress and blankets forced cooled air
Frequently used but not
very effective in
reducing temperature
rapidly
Efficient and effective
method for induction
and maintenance of TH
Effectiveness depends on
strength of air blowing
through the small wholes
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
Cooling garments gel cooling adhesive pads
Both cooling methods very efficient for
induction and maintenance of TH
Nearly as efficient as intravascular cooling
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
Intravascular cooling method
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
50 were allocated to one of the 5 different cooling methods in a
consecutive order
Met criteria for NT or TH
Conventional Cooling
using Ice backs
External coolingusing water cooled
body wraps
External coolingcirculating air
External coolingusing water cooled
self adhesivepads
Intravascular cooling
Ref 28
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
Significant faster cooling using water circulated gel
coated adhesive pads orintravascular cooling
compared to other methods
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
With the Intravascular cooling method the core body
temperature is significantly less frequently out of range
and also by significantly lower absolute temperature
difference
BR Water circul
CC Air circulating
AS Gel coated
CG Intravascular
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
Conclusion
Water circulation gel coated and the intravascular cooling
method are equally efficient for induction of TH or NT
The intravascular cooling method is significantly superior for the
maintenance of the target temperature compared to any
other method
Unknown if this if of any clinical significance No large
randomized trial been done to date
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
HOW TO START A TH PROGRAM
1 Need a champion
1 Best candidate
1 Medical or Neuro-Intensivist
2 Cardiologist
3 Emergency department physician
2 Create a TH Committee with representatives from
1 ED
2 Neurology Neurosurgery
3 Anesthesiology
4 Cardiology
5 Intensive care unit (MICU Neuro-ICU CCU)
6 Nursing from ED and participating ICU
7 Pharmacy
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
3 Do a comprehensive review of the literature
4 Assess local available resources
1 ICU beds
2 Nurse staffing
3 Cooling options
4 Cardiac Cath laboratory
5 Discuss indication and contraindication
1 Grey zone (eg Pregnant women in-hospital SCA non-
shockable rhythm) and consensus needs to be reached
6 Address how to address possible adverse events
1 Shivering
2 Infection
3 Shock
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
7 What device you want to use to achieve target temperature
1 Know possible complications and advantages for each device
8 Develop an easy to follow protocol based on above decisions
and post it on the intranet so it can be easily found
9 Education
1 Ensure all staff including residents attending physicians nursing
are adequately educated
1 On the TH protocol
2 The device ndash especially on how to troubleshoot it
3 Use simulation laboratory if available
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
10 Consider implementation of a TH team that can be reached
24 hours a day by an easy to remember number (eg hellip -
COOL)
11 Increase awareness
1 Lectures
2 Laminated signs in ED and ICU to serve as reminder
12 Regular TH Committed meetings to
1 Ensure quality measures reached and comparable to published
data
2 Update the protocol based on experience and new published
data
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
THERAPEUTIC HYPOTHERMIA (TH)
John Stroger Hospital of Cook County
DID YOUR PATIENT SUFFER A WITNESSED SUDDEN CARDIAC ARREST
If YES has the physician assessed the patients inclusionexclusion criteria
If YES is the patient considered a candidate for Therapeutic Hypothermia
If YES emphasize to physician to initiate TH ASAP as per protocol
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
THE PROTOCOL FOR
THERAPEUTIC
HYPOTHERMIA
AT STROEGER
HOSPITAL
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
HOW TO OBTAIN TH PROTOCOL
1 Cch-intranet
2 Critical Care tap
3 Therapeutic hypothermia tap
4 TH protocol in pdf file
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
QUESTIONS
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
Bibliography
1 Travers AH Rea TD Bobrow BJ Part 4 CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S676-684
2 Nichol G Thomas E Callaway CW Hedges J Powell JL Aufderheide TP Rea T Lowe R Brown T Dreyer J Davis D IdrisA Stiell I Resuscitation Outcomes Consortium InvestigatorsRegional variation in out-of-hospital cardiac arrest incidence and outcome JAMA 2008 300 1423-1431
3 McNally B Robb R Mehta M Out-of-Hospital Cardiac Arrest Surveillance mdash Cardiac Arrest Registry to Enhance Survival (CARES) United States October 1 2005ndashDecember 31 2010 MMWR 2011 60 1-19
4 Stroumlmsoumle A Svensson L Axelsson AringB Claesson A Goumlransson KE Nordberg P Herlitz J Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival European Heart Journal 2015 36 863ndash871
5 Kolte D Khera S Aronow WS Palaniswamy C Mujib M Ahn C Iwai S Jain D Sule S Ahmed A Cooper HA FrishmanWH Bhatt DL Panza JAFonarow GC Regional Variation in the Incidence and Outcomes of In-Hospital Cardiac Arrest in the United States Circulation 2015 1311415-1425
6 Bergum D Nordseth T Mjoslashlstad OC Skogvoll E Haugen BO Causes of in-hospital cardiac arrest ndash Incidences and rate of recognition Resuscitation 2015 87 63-68
7 Sandroni C Nolan J Cavallaro F Antonelli M In-hospital cardiac arrest incidence prognosis and possible measures to improve survival Intensive Care Medicine 2007 33 237-245
8 Berger R Kelley M Survival after in-hospital cardiopulmonary arrest of non-critically ill patients a prospective study Chest1994 106 872ndash79
9 Edgren E Kelsey S Sutton K Safar P The presenting ECG pattern in survivors of cardiac arrest and its relation to the subsequent long-term survival Brain Resuscitation Clinical Trial I Study Group Acta Anaesthesiol Scand 1989 33 (4)265-271
10 Bosson N Kaji AH Niemann JT Eckstein M Rashi P Tadeo R Gorospe D Sung G French WJ Shavelle D Thomas JL Koenig W Survival and Neurologic Outcome after Out-of-Hospital Cardiac Arrest One year after regionalization of Post-Cardiac arrest Care in a large Metropolitan Area Preshospital Emergency Care 2014 18 217-223
11 Polderman KH Induced hypothermia and fever control for prevention and treatment of neurological injuries Lancet 2008 371 (9628) 1955-1969
12 Leonov Y Sterz F Safar P Radovsky A Oku K Tisherman SStezoski SW Mild cerebral hypothermia during and after cardiac arrest improves neurologic outcome in dogs J Cereb Blood Flow Metab 19901057ndash70
13 Sterz F Safar P Tisherman S Radovsky A Kuboyama K OkuK Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs Crit Care Med199119379ndash89
14 Safar P Xiao F Radovsky A Tanigawa K Ebmeyer U BircherN Alexander H Stezoski SW Improved cerebral resuscitation from cardiac arrest in dogs with mild hypothermia plus blood flow promotion Stroke 199627105ndash13
15 Bernard SA Jones BM Horne MK Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest Ann Emerg Med August 199730146-153
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9
16 Yanagawa Y Ishihara S Norio H et al Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest Resuscitation 19983961ndash6
17 Bernard SA Gray TW Buist MD et al Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia N Engl J Med 2002346557ndash63
18 Hypothermia after Cardiac Arrest Study Group Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest N Engl J Med 2002346549ndash56
19 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 75 Postresuscitation Support Circulation 2005 112 24 Suppl IV84 -88
20 Peberdy MA Callaway CW Neumar RW Geocadin RG Zimmerman JL Donnino M Gabrielli A Silvers SM ZaritskyAL Merchant R Vanden Hoek TL Kronick SL American Heart Association Part 9 post-cardiac arrest care 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010 122(18 Suppl 3) S768-786
21 Callaway CW Donnino MW Fink EL Geocadin RG Golan E Kern KB Leary M Meurer WJ Peberdy MA Thompson TM Zimmerman JL Part 8 Post-Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2015 132 S 465-S 482
22 Callaway CW Soar J Aibiki M Boumlttiger BW Brooks SC Deakin CD Donnino MW Drajer S Kloeck W Morley PT Morrison LJ Neumar RW Nicholson TCNolan JP Okada K ONeil BJ Paiva EF Parr MJ Wang TL Witt J Advanced Life Support Chapter Collaborators Part 4 advanced life support 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Circulation 2015 132 S 84-S145
23 Don CW Longstreth WT Jr Maynard C Olsufka M Nichol G Ray T Kupchik N Deem S Copass MK Cobb LA Kim F Active surface cooling protocol to induce mild therapeutic hypothermia after out-of-hospital cardiac arrest a retrospective before -and-after comparison in a single hospital Crit Care Med 2009 December 37(12) 3062ndash3069
24 Dumas F Grimaldi D Zuber B Fichet J Charpentier J Pegravene F Vivien B Varenne O Carli P Jouven X Empana JP Cariou A Is Hypothermia After Cardiac Arrest Effective in Both Shockable and Non-Shockable Patients Insight from a large registry Circulation 2011 123 877-886
25 Sung G Bosson N Kaji AH Eckstein M Shavelle D French WJ Thomas JL Koenig W Niemann JT Therapeutic Hypothermia After Resuscitation From a Non-Shockable Rhythm Improves Outcomes in a Regionalized System of Cardiac Arrest Care Neurocritical Care 2015 EPub
26 Arrich J MD The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group Clinical application of mild therapeutic hypothermia after cardiac arrest Crit Care Med 2007 351041ndash1047
27 Kory P Fukunaga M Mathew JP Singh B Szainwald L Mosak J Marks M Berg D Saadia M Katz A Mayo PH Outcomes of Mild Therapeutic Hypothermia After In-Hospital Cardiac Arrest Neurocritical Care 2012 16 406-412
28 Hoedmaekers CW Ezzahti M Gerritsen A Van Der Hoeven JG Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients a prospective study Critical Care 2007 11 1-9