Hypothermic protocol

[Bostonredsox]

anyone have any good protocols they can share with me? One of our new younger cardio guys, our intensivist and I were talking about this last night. Had a Vfib arrest with probable STEMI come in after being shocked like 5 times in the field last night. Massive cerebral edema, ph 6.9 despite vent and bicarb drip, just toast right from the door. Was still alive when I left this morning I am sure she wont be when I get back tonight. Anyway, was talking to cardio about inducing hypothermia for cardioprotection. Turns out we didnt need to as the cerebral edema knocked out her hypothalamus as her temp was 84.5 on its own...but that got us to talking about it. From what I understand it just requires a fem line, some tubing, cold saline and a special infusion machine. Sounds like it wouldnt be too outrageously expensive. Want to ome up with something to propse to administration now that the new year is upon us and theyll actually spend some money.
thanks as always.

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[core0]

anyone have any good protocols they can share with me? One of our new younger cardio guys, our intensivist and I were talking about this last night. Had a Vfib arrest with probable STEMI come in after being shocked like 5 times in the field last night. Massive cerebral edema, ph 6.9 despite vent and bicarb drip, just toast right from the door. Was still alive when I left this morning I am sure she wont be when I get back tonight. Anyway, was talking to cardio about inducing hypothermia for cardioprotection. Turns out we didnt need to as the cerebral edema knocked out her hypothalamus as her temp was 84.5 on its own...but that got us to talking about it. From what I understand it just requires a fem line, some tubing, cold saline and a special infusion machine. Sounds like it wouldnt be too outrageously expensive. Want to ome up with something to propse to administration now that the new year is upon us and theyll actually spend some money.
thanks as always.

We just use a cooling blanket which we have any way. I think there is a special blanket that has a head chest and thigh wraps. Works OK. Other units use the Artic Sun http://www.medivance.com/arcticsun5000. Our nurses don't like it because it takes off skin in the undernourished when it comes off. There are a variety of catheters that you can use also. We cool just about everyone that arrests anymore if its over 5 minutes downtime. Essentially the neuro critical care folks extrapolate this from the outpatient v-fib and v-tach arrest data.

You need to develop an entire protocol though. The amount of cooling is regulated when to rewarm and what to do about shivering etc.

 

[Hernandez]

I've seen both ice packs and the cool-guard catheter.....the cool guard is so much easier to regulate than ice packs.

But my hospital over does it, the data is really only in out of house vfib-tach arrests yet the peeps who run it (ER, why I have no clue) does even PEA. he'll, sometimes you have to drag them away and point out the ICH to stop them.

 

[pseudoknot]

But my hospital over does it, the data is really only in out of house vfib-tach arrests yet the peeps who run it (ER, why I have no clue) does even PEA.

There haven't been enough survivors from non VF arrests to have any significant data one way or the other. There certainly is not robust data showing hypothermia doesn't work in non VF/VT arrests. There's also no clear physiologic reason why the rhythm would matter. At the moment it's appropriate to cool everyone. That may change in the future when we have bigger data sets.

 

[Hamhock]

Anyway, was talking to cardio about inducing hypothermia for cardioprotection. .

Do you mean for cerebroprotection or cardioprotection?

HH

 

[Hamhock]

anyone have any good protocols they can share with me? .

http://www.med.upenn.edu/resuscitation/hypothermia/protocols.shtml

That should be enough!

HH

 

[Bostonredsox]

http://www.med.upenn.edu/resuscitation/hypothermia/protocols.shtml

That should be enough!

HH

Thanks man. Printed it and went over it with intensivist and our more proative interventional cardio guy. Giving it to administration this week.

 

[nlax30]

I was also going to suggest that UPenn site... a lot of good info there and it's what we based a lot of our protocols on.

Currently we use the Gaymar external cooling device with leg and torso vests. Our goal temp active cooling to 33deg C for 24 hours then passive rewarming.

We also do TH for any rhythms on out of hospital arrests and consider it for in hospital arrests though in many instances the in hospital arrests have other co-morbidities that seem to usually fall under our exclusion criteria.

But basically our ED screens the patient for TH based on our criteria and then contacts a Pulm/CC doc, cardiologist, and neurologist to initiate it. Central line is placed, external cooling is applied and it begins.

The main issues we've run into during the cooling phase are chasing electrolytes and arrhythmias. We're also using paralytics more and more only during the active cooling phase to prevent shivering and then turning them off during maintenance phase.

Have had a few good outcomes from it and it was quite the learning experience when it was first implemented here little over a year ago. First few we're a mess with ED folks running around with protocol sheets trying to figure out what to do next or who was going to do what. We've also had to have cardio step in a few times when ED wanted to cool a post code arrest with likely an unknown downtime and already massive cerebral edema on CT.

 

[Bostonredsox]

Being a critical care bound resident at a for profit community shop blows. I was told we are getting ice packs....FML

 

[nlax30]

I'm at a community DO for-profit shop as well, so was kind of surprised the equipment and support we got. Do have cardio fellowship here and the cardio PD has a fair bit of say and is well respected so he spearheaded the protocol here.

 

[Bostonredsox]

I'm at a community DO for-profit shop as well, so was kind of surprised the equipment and support we got. Do have cardio fellowship here and the cardio PD has a fair bit of say and is well respected so he spearheaded the protocol here.

Yeah we are DO for profit, only a few years old. Administration sucks here, none of them care about outcomes or standards of care, just their bonus at the end of the year. Slowwwwwly changing I think.

 

[pseudoknot]

Being a critical care bound resident at a for profit community shop blows. I was told we are getting ice packs....FML

The studies showing benefit were done with ice packs and cold saline. I know it's not as sexy but it doesn't really matter.

 

[Bostonredsox]

The studies showing benefit were done with ice packs and cold saline. I know it's not as sexy but it doesn't really matter.

I know I know but c'mon, its 2013. Seeing a pt with ice packs all over just looks so archaic to me. Seeing the fem line into the arctic sun or Gaymar with the nice humming sounds just seems...awesome..-er.

 

[turkeyjerky]

I know I know but c'mon, its 2013. Seeing a pt with ice packs all over just looks so archaic to me. Seeing the fem line into the arctic sun or Gaymar with the nice humming sounds just seems...awesome..-er.

Are you saying that you're just going to be using ice packs, or ice packs + cold saline? If the former, than you really need to be doing the latter. Honestly, there's no reason to be sad about the lack of the fancy stuff--cold saline is just as fast as anything, and it's a great way to get people to give these patients enough fluid.

 

[Hamhock]

Are you saying that you're just going to be using ice packs, or ice packs + cold saline? If the former, than you really need to be doing the latter. Honestly, there's no reason to be sad about the lack of the fancy stuff--cold saline is just as fast as anything, and it's a great way to get people to give these patients enough fluid.

Agree -- and I would go a bit further:

-forget the ice packs -- cold saline is faster and better and less messy
-I am sure you could convince your profit-driven admin that sticking a few bags of saline in a fridge isn't that much more expensive that ice packs

I have worked in a few centers now and developed a couple of protocols and none of them have used ice packs -- only iced saline for induction.

The problem comes when you try to maintain a steady temp between 32-34 with only saline and a cooling blanket for 24 hours.

That -- and controlled warming -- are MUCH easier with expensive toys.

HH

 

[Bostonredsox]

Agree -- and I would go a bit further:

-forget the ice packs -- cold saline is faster and better and less messy
-I am sure you could convince your profit-driven admin that sticking a few bags of saline in a fridge isn't that much more expensive that ice packs

I have worked in a few centers now and developed a couple of protocols and none of them have used ice packs -- only iced saline for induction.

The problem comes when you try to maintain a steady temp between 32-34 with only saline and a cooling blanket for 24 hours.

That -- and controlled warming -- are MUCH easier with expensive toys.

HH

This is why I want the machine. How the hell else do you go about controlled rewarming?

 

[TrustMe]

This is why I want the machine. How the hell else do you go about controlled rewarming?

Tough to control without the fancy machines. We used Therma-Guard setup where I trained. Easy to place and cooled/warmed with great control and precision. Really liked it. Where I am now they have InnerCool. Good cooling. Bad warming. Very cumbersome to place. Don't like it.

 

[Bostonredsox]

Our efforts have paid off. Stryker rep came today brought one of their gaymar units. We're trialing it for a few weeks. It's significantly cheaper than an arctic sun (38k) so from what I took from our CC meeting today and best practice going forward, sounds like administration is going to buy it. They are using them at nearby Wake Forest too which we have some connections too, think that may have also helped sway them.