Therapeutic hypothermia

Background

• Determination of Neurologic Prognosis is unreliable before at least 72 hours after ROSC. Do not neuroprognosticate until 72 hours post rewarming.
• Greatest benefit in out-of-hospital V-fib, though evidence suggests hypothermia helps in other dysrhythmias
• Two most likely mechanisms of action:
  • Reduces cerebral metabolism by 6-8% per degree C
  • Reduces oxygen free radical production and lipid peroxidation
• Cooling to 32-34ºC was found in initial studies, current studies suggest 36ºC to have same benefits

Exclusion/Contraindications

• >12hrs since ROSC
• Glasgow Motor score >5
• Minimal pre-morbid cognitive status
• Unable to maintain SBP > 90 mmHg, with or without pressors, after CPR
• Other reason for coma
  • intracranial pathology (i.e. intracranial hemorrhage, ischemic stroke)
  • subarachnoid hemorrhage
  • sedation
• Sepsis as etiology for arrest
• DNR/DNI status
• Uncontrollable bleeding or known bleeding diathesis with active bleeding
• Significant trauma (especially intra-abdominal)

Sedation and Paralytics

Should administer one or more of the following:

• Fentanyl Injection 50 mcg IV every hour as needed for pain.
• Fentanyl IV infusion NSS
• Propofol IV infusion
• Lorazepam IV infusion
• Lorazepam Injection 1 mg IV every 2 hours as needed for agitation.
• Pancuronium IV infusion
  • Initiate before initiating cooling. Dosing recommendations: 0.1 mg/kg loading dose followed by a continuous infusion of 0.33-2 mcg/kg/minute.
  • Do not use in patients with renal and/or hepatic insufficiency.

Prevention of shivering is important to avoid warming and needless oxygen consumption

• May require train of four monitor with goal of 1-2/4 twitches with neuromuscular blockade
• Lower doses of NMB work against shivering
• Higher doses of NMB used to paralyze the diaphragm in these scenarios:
  • Need to decrease O2 consumption
  • Decrease plateau pressures
  • Hypoxemia is present

Workup

• Labs

1. ABG q6 hrs for duration of hypothermia
2. CBC, Coags, BMP, Mg, Phos q6 hrs for duration of hypothermia (expect decreased K, Ca, Mg, Phos during, and rebound at rewarming)
3. Troponins, CK-MB q6 hrs x2 days
4. Lipase, LFTs (if abnormal, no need to intervene unless persistent after rewarming)
5. Other - Cortisol, UA, Pan-cultures, tox screen

• Monitoring

1. EKG q8 r/o ACS
2. Arterial line
3. Foley with temp probe
4. CVP, ScvO2

Management

• Consider head CT
• Head of bed at 30 degrees
• Goal MAP 80 - 100 mmhg
  • Titrate with norepinephrine (start 2-4 mcg/min) if EF > 50%
  • Titrate with dobutamine (start 2.5-20 mcg/kg/min) if EF < 50%
  • IV NTG starting at 10 mcg/min if HTN
• Check skin q2-6 hrs for cold injury
• Maintain tight BG control, 110-150 mg/dL
• Replete K, Mg, Phos, Ca (hypothermia induced diuresis is expected)
• Common unconcerning ECG findings during cooling - Osborne wave, HR < 40 bpm
• Consider continuous EEG within 6 hrs, no later than 12 hrs after onset of cooling
• Stress dose steroids for adrenal insufficiency

Cooling

• Cool to 32-34ºC as soon as possible (within 4 hours)
• Initiate rewarming 24 hrs after target temperature was reached
• Cooling methods
  • Maintain at 32-34ºC with 2 cooling blankets to sandwich the pt, with sheets covering the blankets to protect skin
  • Alternatively, use heat exchange device or 4°C IVF at 30 cc/kg over 30 min
  • Supplement with ice packs to groin, chest, axillae, neck until 34ºC reached
• Prevention of shivering and paralysis - pancuronium at 0.1 mg/kg load, follow with 1 mcg/kg/min infusion (cisatracurium if renal or hepatic impairment)

Rewarming

• If severe dysrhythmia/BP instability/bleeding develops, rewarm pt
• D/c K infusions (extracellular K increases)
• Keep paralytic and sedative until rewarmed
• Slow rewarm at 0.5°C to target of 36°C

Disposition

• ICU admission

See Also

Hypothermia Cardiac Arrest Links

• Therapeutic Hypothermia
• TTM Trial
• Cardiac Arrest
• Post Cardiac Arrest
• Hypothermia
• HACA

Source

• University of Pennsylvania Targeted Temperature Management Protocol
• eMedicine - Adler, Jonathan et Al. Therapeutic Hypothermia.