Induced Hypothermia

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Bostonredsox

Bostonredsox

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Had our first case. 77 y/o Vfib arrest. we bought the gaymar machine about 2 months ago. program went live last week. Had first case on Thursday. protocol went smoothly. was actually cooled via ER fluids. Kept him down. BIS monitoring, nimbex TOF, versed/fentanyl. Neuro + Cardio involved Friday morning. went fixed and dilated late afternoon Friday. MAP in 40s on levo/vaso/dobut. family said stop. warmed him up, BIS was like 9.

In hindsight it was really hard to see but cards thinks there was a posterior STEMI on one of the ekgs after rosc late thurs night. I looked at it with him friday afternoon, still cant see it in my none cardio trained eyes. probably should have gone to cath then though I guess.

reaper 1 - IH 0.
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Bostonredsox said:
Had our first case. 77 y/o Vfib arrest. we bought the gaymar machine about 2 months ago. program went live last week. Had first case on Thursday. protocol went smoothly. was actually cooled via ER fluids. Kept him down. BIS monitoring, nimbex TOF, versed/fentanyl. Neuro + Cardio involved Friday morning. went fixed and dilated late afternoon Friday. MAP in 40s on levo/vaso/dobut. family said stop. warmed him up, BIS was like 9.

In hindsight it was really hard to see but cards thinks there was a posterior STEMI on one of the ekgs after rosc late thurs night. I looked at it with him friday afternoon, still cant see it in my none cardio trained eyes. probably should have gone to cath then though I guess.

reaper 1 - IH 0.
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I always CT head, CTPE these people, and get cards to do echo on em in ER. Cath emergently.

VFIB in normothermic pt over age 30 is MI until proven otherwise.

Remember to NOT cool em if require more than 1 pressor, SPO2 <85 after mech vent, >6h ROSC, septic, head bleed, coagulopathic/dic, major trauma

Dont bother expecting much in terms of neurologic recovery early rewarm and give em until 72h post rewarm to get concerned. They are often fixed, dilated, abscent CN's afterward but do recover later
 
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At our shop fixed, dilated, and absent CN function afterward = confirmatory testing for brain death via CTA or NM scan. In our experience, absent cranial nerve function 72 hours after arrest is an incredibly poor predictor of meaningful neurologic outcome.
 
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Neuro recovery: re-eval at 72h post arrest
Anoxic-ischemic encephalopathy
-50% brain damage
-10% back to baseline
-20% have "meaningful" neuro recovery.
Bad prognosis if:
1) pupillary reflex abscent
2)no motor response to nox stim.
If only extensor reflex gotta reval
at day 6 post code!!!!
3)corneal reflex
4)myoclonic status epilepticus (bilat synch twitch face/arm/trunk/axial. Upward deviation of open eyes)

This is all great for BRAINSTEM **** but what about cortex eval?
-somatosensory evoked potentials or SSEP. Stim median nerve, measure response in->brachial plexus ->c-spine -> finally in somatosensry cortex (do all this to maksure pathway to brain intact)
This is THE test. Do at 72h post arrest. If no response in brain= toast. Even if do have response 50% never regain consciousness.

CT scan useless for outcome
MRI questionable value
EEG questionable prognostic value, but actually good to use DURING hypothermia to eval for sz in paralyzed pts.

Lastly, 2 weeks is max for final outcome USUALLY. Pt either:
1)brain dead
2)vegetative: if > 3months then PERMANENT.
3)recovers

NOBODY who was comatose after 15 minutes of CPR survives past 6weeks!!!!

Check out american Academy Neurology prognostic guidelines.
 
No blood flow to the brain on CTA at 72hrs = totally fuct
 
We put so many people on hypothermic protocol its ridiculous. I dont agree with inappropriate pt selection done via ER and attendings. But looking at some 21yr old vfib arrest who was given CPR by his coach on the football field and saying because he has absent CN reflexes right after rewarm and calling him fuct is obviously wrong. Dude was responsive in 24h and extubated in 36h post rewarm. Saw hin 1mo later looked and acted like a 21yr old, just with an AICD bump in his L pec.
 
VentdependenT said:
Ok buddy. Havin zero goin on upatairs at 72h is bad.

What guidelines did you learn about neuro recovery from?
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Presumably the same as you. For example the AAN guidelines you referred to above include a decision algorithm that recommends brain death testing in patients with coma/absent cranial nerve function. That is precisely the patient you are describing that you had suggested wakes up. Our experience may just be different than yours. We just don't see patients with absent cranial nerve function 72 hours post arrest having a meaningful recovery, most are brain dead, or close. Instead of waiting several more days (5-7) for reliable motor exam I would send them for a blood flow study because they look dead, that's all I was suggesting in my initial response.
 
We use the same Gaymar machines with wraps for our hypothermia pts.

Our protocol has been active for a little over a year now, mostly based on UPENN's hypothermia protocol.

First few cases were a mess, between deciding who was actually running the show, to fights with the ER on who should and shouldn't be cooled.

Now we have specific attendings that have "hypothermia priveledges" and for each case there has to be Cards, Pulm/ CC, and Neuro on board. Usually it's Cards and Pulm/CC running things initially since the cardio fellow comes in and there's always residents in house who cover several of our Pulm/CC attendings.

Initially we were hesitant to paralyze but lately I've seen nimbex used more and more, at least during the active cooling stage and then stopped. I know at least 1 or 2 of our neurologists are likely going to start doing continuous EEG on the ones they're involved with.

Unfortunately I'm on call tomorrow and I think we had two hypothermia cases start today. :(

Are y'all doing all initial rhythms or just vfib/vtach? Technically we're considering it in all arrests (within certain timeframes of course) but I think PEA arrests may be taken out next time we tweak our protocol.
 
Phlegm said:
Presumably the same as you. For example the AAN guidelines you referred to above include a decision algorithm that recommends brain death testing in patients with coma/absent cranial nerve function. That is precisely the patient you are describing that you had suggested wakes up. Our experience may just be different than yours. We just don't see patients with absent cranial nerve function 72 hours post arrest having a meaningful recovery, most are brain dead, or close. Instead of waiting several more days (5-7) for reliable motor exam I would send them for a blood flow study because they look dead, that's all I was suggesting in my initial response.
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I agree. I meant you cant call em fuct UNTIL 72h mark. apologies. I also should have been clearer about absent CN's. They are often absent soon after post rewarm but should return before 72h mark. If they dont then we call neuro depending on pt age and comorbidities
 
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nlax30 said:
We use the same Gaymar machines with wraps for our hypothermia pts.

Our protocol has been active for a little over a year now, mostly based on UPENN's hypothermia protocol.

First few cases were a mess, between deciding who was actually running the show, to fights with the ER on who should and shouldn't be cooled.

Now we have specific attendings that have "hypothermia priveledges" and for each case there has to be Cards, Pulm/ CC, and Neuro on board. Usually it's Cards and Pulm/CC running things initially since the cardio fellow comes in and there's always residents in house who cover several of our Pulm/CC attendings.

Initially we were hesitant to paralyze but lately I've seen nimbex used more and more, at least during the active cooling stage and then stopped. I know at least 1 or 2 of our neurologists are likely going to start doing continuous EEG on the ones they're involved with.

Unfortunately I'm on call tomorrow and I think we had two hypothermia cases start today. :(

Are y'all doing all initial rhythms or just vfib/vtach? Technically we're considering it in all arrests (within certain timeframes of course) but I think PEA arrests may be taken out next time we tweak our protocol.
Click to expand...

You have to paralyse
 
The thing I like about cooling? You get to punt for like 24 hours. Heh.

The only time I think it really has a lot of utility is fulminate liver failure. The out of hospital arrest stuff (VF and VT)? Eh. Whatever.
 
The 21 y/o makes sense venty. they have a good chance of surviving.

My guy was almost 80 and not the best protoplasm to start with and was down atleast 15 min in the field. To me its a waste of resources but the European and Australian studies that started this have NNTs of like 6 and 4 respectively, hard to argue against giving them a shot.

I also agree with Cath. He should have gone. I picked him up already cooled from another resident but in hindsight I should have pushed for cards to take him to the lab.

We don't have any ER fights. They want nothing to do with it other than calling for the process to start. They revived to ROSC, called "code cool", MICU resident comes down and sets up the machines, places the lines and coordinates cath lab, eeg's and such.

Agree with JDH. If theyre shivering, they get paralyzed. once they are, you cant tell if they're seizing, so there's your eeg. If not shivering, why would I paralyze other than for vent dysynchrony/ARDS as per ususal, which I doubt many of these patients experience.

And I agree about the 72hour marks. We didn't stop because of the fixed and dilated. We stopped, or rather family said stop, because vaso/levo and dobut could barely maintain a map over 50 and we were only 36 hours in. Im quite sure even with the 50% roughly decrease in brain cell metabolic oxygen consumption 2/2 hypothermia, he couldn't have been getting any measurable amount of cerebral oxygen delivery with that MAP for that long.
 
jdh71 said:
You don't necessarily have to. The paralysis is only to prevent complications from shivering, and if the patient isn't doing that, why paralyze them?
Click to expand...

Im not going to read all about shivering and cerebral/brainstem function vs spinal cord reflex vs local muscle response to cold or nonvisible muscle fasiculations but its part of the protocol so I do it.

BUT I come here to have you guys challenge and fine tune my practice, so i guess i WILL read about it AND probably change the way I practice.
 
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VentdependenT said:
Dont bother expecting much in terms of neurologic recovery early rewarm and give em until 72h post rewarm to get concerned. They are often fixed, dilated, abscent CN's afterward but do recover later
Click to expand...

I'd like to know where you get that info. Neuro exam while cooled is worthless, but everywhere I've trained will call it once they're normothermic, and if they have only 1-2 reflexes, unless they recover much within 48 hours, their prognosis seems to follow the originial plum & posner's data that they're heading to a greenery.....
 
VentdependenT said:
Im not going to read all about shivering and cerebral/brainstem function vs spinal cord reflex vs local muscle response to cold or nonvisible muscle fasiculations but its part of the protocol so I do it.

BUT I come here to have you guys challenge and fine tune my practice, so i guess i WILL read about it AND probably change the way I practice.
Click to expand...

Short lazy answer I give the terns is oxygen consumption, shivering can utilize a lot that you'd prefer to go to the brain. But that's a very base answer, and like JDH, I don't paralysis unless they actually are shivering.
 
Hernandez said:
I'd like to know where you get that info. Neuro exam while cooled is worthless, but everywhere I've trained will call it once they're normothermic, and if they have only 1-2 reflexes, unless they recover much within 48 hours, their prognosis seems to follow the originial plum & posner's data that they're heading to a greenery.....
Click to expand...

agreed. most of them I think we know are dead long before they're rewarmed. But your technically not dead until your warm and dead.
 
Hernandez said:
I'd like to know where you get that info. Neuro exam while cooled is worthless, but everywhere I've trained will call it once they're normothermic, and if they have only 1-2 reflexes, unless they recover much within 48 hours, their prognosis seems to follow the originial plum & posner's data that they're heading to a greenery.....
Click to expand...

From all the crap I read. our neuro dudes wont even see the pt until 72h have passed. Post me a link. Learn me something.

You douchesacks were right about the shivering stuff. Cant say Ive palpated the masseters or watched the 12 lead for shivering. Again, its what our protocol calls for. Now I can challenge that if I feel like I need a cause when Im bored.
 
namethatsmell said:
What aspects of cooling for out of hospital arrests are "eh?" The data seems pretty solid.
Click to expand...

Let's talk about the data.

Tell me about it.

f_2a0ec29bef.jpg
 
VentdependenT said:
From all the crap I read. our neuro dudes wont even see the pt until 72h have passed. Post me a link. Learn me something.
Click to expand...

The AAN guidelines only specify for brain death they be normothermic, which they don't define. If you pull plum & posner's book stupor and coma, they have data on recovery based off of neuro exam. They're data is based off of neuro exam after 48 hours, so I gues ehour neuro is 48 + 24 for cooling. But brain dead is brain dead, and oh having a 1 or 2 brain stem signs is a bad prognostic sign no matter how you slice it.
 
jdh71 said:
Let's talk about the data.

Tell me about it.

f_2a0ec29bef.jpg
Click to expand...

Heh, nice callout with Willy (an attending I like makes the same pose when pimping us).


The two major NEJM randomized trials of OHCA patients with VF you've probably read:

-Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557- 563.
---->59% of cooled pts survived compared to 45% of controls

-Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346: 549 &#8211; 556.
---->49% of cooled pts survived compared to 26% of controls


Rather than quote a bunch of small studies, here's a lit review of 13 of them:

-Sagalyn E, Band RA, Gaieski DF, Abella BS. Therapeutic hypothermia after cardiac arrest in clinical practice: review and compilation of recent experiences. Crit Care Med. 2009 Jul; 37(7 Suppl):S223-6.
----> Cooled patients had increased survival/favorable outcome with an OR of 2.5


Two recent systematic review/meta-analysis finding cooling to be associated with improved outcomes in post-arrest patients:

Arrich J, Holzer M, Havel C, Müllner M, Herkner H. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev. 2012 Sep 12;9:CD004128.

Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW. Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. Resuscitation. 2012 Feb;83(2):188-96. doi: 10.1016/j.resuscitation.2011.07.031.


Now I ain't no googly-eyed fanboy. The 2nd meta-analysis I listed notes (quite fairly) the limitations/low quality of several studies on hypothermia in post-arrest patients. It's tough to blind providers in a hypothermia trial. The level of standardization of reporting things like cooling rates, adverse events, outcomes/endpoints could be higher. The exact mechanism of how cooling works isn't known and it's also been argued that the big benefit of cooling could simply be the avoidance of fever. These are things that should (and will likely) be addressed.

All things considered, limitations in mind, I think the data is solid enough to earn most out-of-hospital VF players a shot at the only neuro-protective tool we have to offer that's been shown to be of benefit for these folks. That being said, areas of cooling are murky and I'm open to being convinced otherwise. Let me know the holes in my thinking.
 
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Strong work putting all that together. I agree there isn't much reason not too but if we are all really honest, it's not like the data is really all that great. So with so much that we do in the ICU, with the data we have, I'm just like "Eh. Whatever". After have done this for awhile, I kind of think patients get better despite much of the stuff we try to do. With that said, in the aggregate patients are living and surviving more often. Why? To much noise. But I tend to think that for all of how much we hate on Rivers and EGDT it did get us all thinking about treating things early and agressively, add th in with the importance placed on actually having intensivists in the unit with modern multi-disciplinary teams rounding and patients do better.

namethatsmell said:
Heh, nice callout with Willy (an attending I like makes the same pose when pimping us).


The two major NEJM randomized trials of OHCA patients with VF you've probably read:

-Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557- 563.
---->59% of cooled pts survived compared to 45% of controls

-Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346: 549 – 556.
---->49% of cooled pts survived compared to 26% of controls


Rather than quote a bunch of small studies, here's a lit review of 13 of them:

-Sagalyn E, Band RA, Gaieski DF, Abella BS. Therapeutic hypothermia after cardiac arrest in clinical practice: review and compilation of recent experiences. Crit Care Med. 2009 Jul; 37(7 Suppl):S223-6.
----> Cooled patients had increased survival/favorable outcome with an OR of 2.5


Two recent systematic review/meta-analysis finding cooling to be associated with improved outcomes in post-arrest patients:

Arrich J, Holzer M, Havel C, Müllner M, Herkner H. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev. 2012 Sep 12;9:CD004128.

Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW. Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. Resuscitation. 2012 Feb;83(2):188-96. doi: 10.1016/j.resuscitation.2011.07.031.


Now I ain't no googly-eyed fanboy. The 2nd meta-analysis I listed notes (quite fairly) the limitations/low quality of several studies on hypothermia in post-arrest patients. It's tough to blind providers in a hypothermia trial. The level of standardization of reporting things like cooling rates, adverse events, outcomes/endpoints could be higher. The exact mechanism of how cooling works isn't known and it's also been argued that the big benefit of cooling could simply be the avoidance of fever. These are things that should (and will likely) be addressed.

All things considered, limitations in mind, I think the data is solid enough to earn most out-of-hospital VF players a shot at the only neuro-protective tool we have to offer that's been shown to be of benefit for these folks. That being said, areas of cooling are murky and I'm open to being convinced otherwise. Let me know the holes in my thinking.
Click to expand...
 
Haven't see those two latest reviews, will have to check them out, thanks.

Just had 2 mid-50's post vfib arrest pts on service go through hypothermia protocol and both walked out of the hospital neurological intact, only had some confusion about recent events but otherwise did well.

Nice/impressive to see when everything comes together and works out well.
 
Do you guys premptively give mg and Ca during the massive cold diuresis that ensues while your cooling them? Was talking with one of our nephrologists on the last pt I cooled. I gave that fu*+er over 10g of mg and 8 amps of calcium before he was warm. Seeing as his EF was like -5 I thought in retrospect having that Ca up front would have helped his abysmal contractility and CO. Maybe it would have helped him perfuse all those organs that subsequently died
 
jdh71 said:
Strong work putting all that together. I agree there isn't much reason not too but if we are all really honest, it's not like the data is really all that great. So with so much that we do in the ICU, with the data we have, I'm just like "Eh. Whatever". After have done this for awhile, I kind of think patients get better despite much of the stuff we try to do. With that said, in the aggregate patients are living and surviving more often. Why? To much noise. But I tend to think that for all of how much we hate on Rivers and EGDT it did get us all thinking about treating things early and agressively, add th in with the importance placed on actually having intensivists in the unit with modern multi-disciplinary teams rounding and patients do better.
Click to expand...

Thanks for the reply. I think your point about the increased attention to early/aggressive therapy makes a lot of sense.

Also, sorry for the delay in responding--have spent the last few days packing up my apartment (blech) and moving to a new city to start residency (woot).
 
Bostonredsox said:
Do you guys premptively give mg and Ca during the massive cold diuresis that ensues while your cooling them? Was talking with one of our nephrologists on the last pt I cooled. I gave that fu*+er over 10g of mg and 8 amps of calcium before he was warm. Seeing as his EF was like -5 I thought in retrospect having that Ca up front would have helped his abysmal contractility and CO. Maybe it would have helped him perfuse all those organs that subsequently died
Click to expand...

Right now on our protocol we're giving 4g Mag at the start of cooling and then lytes are being check q6. They're placed on our ICU's electrolyte replacement protocol so it's for the most part on autopilot unless something comes back markedly abnormal.

Not sure I've had to give much calcium though. We are checking ionized calcium though as well with the serial labs.
 
Heh awww I feel like I'm sorta being called out. Maybe 33 ain't the right temp, who knows where the winds may blow next?

The survival in both groups is crazy high and focusing on actively maintaining temp control is likely still a good idea (as the editorial suggests).

The study is kind of a "Euuurope, F**K Yeah!" tribute--their survival is...so...high. Compare this to some of the (somewhat heterogeneous) studies out of some major US cities (ie ~1% neuro-intact survival for out of hosp CA) in the last decade and it kinda makes whatever American pride you got on the topic just shrivel up. Although I'm an intern so maybe I'm just well conditioned for that.
 
namethatsmell said:
Heh awww I feel like I'm sorta being called out. Maybe 33 ain't the right temp, who knows where the winds may blow next?.
Click to expand...

This ain't a call out, this is an homage to the CC circle of life. All of this has happened before and will happen again. (Except CVP, Paul Merik will personally eventually kidney shank anyone who still uses it) And most of what we do is based on crap data that will NEVER be repeated or duplicated. My philosophy, don't be the first to adopt a new practice, but don't be the last....and if the data sounds too god to be true (cough proning..cough) then it is........
 
Hernandez said:
This ain't a call out, this is an homage to the CC circle of life. All of this has happened before and will happen again. (Except CVP, Paul Merik will personally eventually kidney shank anyone who still uses it) And most of what we do is based on crap data that will NEVER be repeated or duplicated. My philosophy, don't be the first to adopt a new practice, but don't be the last....and if the data sounds too god to be true (cough proning..cough) then it is........
Click to expand...

Heh sorry, I was being kinda facetious with the "call out." I dig the "CC circle of life" homage.

So out of curiosity, is this paper going to change your cooling practice now? Deter you guys from cooling below 36? Make you less likely to cool at all?
 
I think this study makes the case that it may be more important to prevent hyperthermic states as opposed to inducing hypothermic states. All of these ischemic-post conditioning methodologies are targeted toward prevention of mitochondrial pore protein activation and subsequent entry into apoptotic pathways right? I think the data is showing that temp control as well as other practices may attenuate apoptotic pathway activation. There's obviously lines that remain to be connected but I think its promising data for the future of resuscitation medicine.
 
I tend to agree that avoiding hyperthermia in patients with neurologic insult is a good idea, which we have seen in patients with SAH, ICH, etc.. We haven't seen cause and effect in those subsets of patients, but we know fever = likely worse neurologic outcome with initial neurologic injury.

As for the TTM trial, it has changed my practice in that most patients get a cool guard or artic sun and get AGGRESSIVE temperature management with a goal of 36 degrees. However, my goal is no longer 32 degrees, battling with hypothermia-related diuresis, electrolyte replacements, shivering, and delayed neurologic examinations. What I don't think people should take away from the TTM is that you can go back to avoiding temperature management at all in post-cardiac arrest patients. If the HACA and bernard studies (total of 360 patients) changed your practice the TTM trial (1000 pts) is likely to change your practice as well. Let's be honest most of the big urban US cities don't have survivals of 50% with CPCs < 2, > 50% bystander CPR (75% in TTM) or vfib/vtach in a majority of patients with OOHCA.
 
The TTM trial has an oddly low number of patients for the number and size of the Scandinavian centers that were screened (should be closer to like 8000 based on information from a colleague of mine who was previously involved with the group and knows the centers well), which makes me wonder if there was some other element of prescreening that the authors blatantly have not accounted for. Also, the 33 degree group at baseline is a bit "sicker" than the 36 degree group, and you have to wonder if therapeutic hypothermia improved otherwise worse outcomes in that group to ultimately show no difference between the two. I work with those who wrote the editorial, and while I have to agree that prevention of fever is obviously going to be of benefit in a neurologically insulted patient, I don't think we can write off the therapeutic benefit of induced hypothermia, especially given the HACA trial and the Bernard trials. What temperature should we cool to? That is the real mystery, but one thing is for certain: rewarming quickly has been proven to be bad, and myoclonus independently confers a poor likelihood of good neurologic outcome, on the order of < 10%.
 
There was some pre-screening; you had to obtain ROSC for > 20 minutes. Which if your colleague was talking about gross numbers of cardiac arrest patients (which is what we mostly think of) then he may have some recall bias since most patients got excluded by not obtaining ROSC at any point during resus or couldn't maintain rosc for > 20 minutes. The bernard study had 77 patients enrolled over 33 months, and the HACA study had 3500 patients screened for enrollment over 5 years, and ultimately only included 275 patients. In terms of size and quality this study is gigantic. As for the hypothermia group being a bit sicker the baseline demographics are almost identical, and not statistically different so Im not sure where that comes from?

I am definitely not saying I have all the answers, how long, how quickly to rewarm, how long to avoid fever, do certain subset of patients requirer deeper hypothermia for neuroprotection are all questions yet to be answered. However, I still think based on this large reasonably well performed RCT all we can say is that until more data comes out 33 isn't better than 36.
 
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