Cardiac arrest/hypothermia/TTM

[sluggs]

I know that this is a controversial topic to some degree, and I have read the studies, the ACLS guidelines and even some retrospective data.
I started work at a new hospital and there are order sets for a number of targeted temperatures, lengths, lytes, and there are no articulated inclusion/exclusion criteria. In general there seems to be laxity about hitting and maintaining targeted temperature.
My thoughts are that there sure be an institutional approach to this, with a single protocol, and at the very least (probably this IS the best practice):
For all cardiac arrest (or at least all wide complex arrest) if a patient is not following commands post-ROSC, the patient should be kept at least below 36 degrees for 24 hours, followed by a minimum of 48 hours below 37.4. Am I way outta line?

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[deleted171991]

Nope. I can see the benefits significantly outweighing the risks for such a benign protocol (i.e. temperature control, not really TH).

Per UTD:
"Goal temperature — We suggest using 36°C for 24 hours in uncomplicated patients who have moderate coma (some motor response), no malignant EEG patterns, and no evidence of cerebral edema on CT scan. We suggest using 33°C for at least 24 hours when coma is deep (loss of motor response or brainstem reflexes), malignant EEG patterns (eg, epileptiform) appear, or early CT scan changes suggesting the development of cerebral edema are detected."

 

[Hernandez]

That's basically what I do, here cards and er is still gung-ho full hypothermia. Hell, they tried to tell me to cool a post arrest who was 29 degrees already. If it gets admitted to me I use regular hypothermia set but changes goal to 35-36 for 24 hours then go from there.

 

[bigdan]

Sluggs -

For all arrests (inside or outside of hospital, with ROSC) I do what you suggested: 36 deg C for 24 hrs, then normothermia/no fever for 48 hrs. Begin "the process" at 72 hrs.

Question I have for the group: What is your timeline for CT head, EEG, and Neuro consult? I'd been sending pt's to STAT head CTs once I saw several minutes of stable BP/HR/rhythm to rule out any acute neuro change as cause for the coma after arrest, but that then delays cooling the patient. I'll withhold my opinion on our neurologists' response to consult requests - I'll simply say that they strongly encourage us waiting until the entire 72 hrs of TTM have passed.

What do you guys do and when?

 

[nlax30]

Cards here, where I did my general fellowship we transitioned to pretty much what you described above. Default of 36c for 24hrs then just fever prevention beyond that though still occasional did 33c for some cases.

If we got involved right away in the ED would try and start cooling while getting a stat CT. We used cooled saline and body wraps circulating cooled water, I think it was the Gaymar unit.

In the protocol there Pulm/CC, Cards,and Neuro all got consulted up front.

 

[jdh71]

I'm 36 for 24 then avoiding fever.

I'll usually go for the EEG/imaging/neuro consult (we have a couple of fantastic neuro hospitalists) after the TTM if 24 if they are looking right for it off of sedation. In most cases unless it's stupidly obvious of bad outcomes (or progression to brain death) I'll try to get families to wait around 72-96 hours before making any sudden moves if the patient wishes are unknown.

 

[CCM-MD]

We do 33 degrees for 24 hours, unless contraindications. There seems to be more problems with shivering at 36 degrees.

 

[deleted547339]

I’m sorry, but neuro is useless in this patient population unless you have to consult them for an EEG.

 

[CCM-MD]

I’m sorry, but neuro is useless in this patient population unless you have to consult them for an EEG.

Agreed... I don't consult them, unless its some stupid "protocol" that they have to be consulted for EEG. I've had situations in the past where the neurologist and I communicated things differently to patient's family and ended up confusing them.

Cardiology is pretty useless too - not needed in all arrests - worth getting them if you think its a cardiac etiology. One of my current patients: hanging injury --> asphyxiation --> arrest. Another one aspirated and coded after a seizure in the neuro floor. Literally nothing for a cardiologist to add in these situations. "Protocolized" medicine/consultation is unnecessary. Physicians need to be allowed to use their brains. Out of hospital V Fib arrest? Get them onboard yesterday.

 

[chessknt]

In terms of contraindications, at 36C I am not convinced there are any unless the patient has cerebral edema progressing to herniation that would predict essentially a guaranteed bad outcome that would make the intervention futile.

I would not cool anyone to 33C if I was concerned about infection or serious bleeding.

 

[jdh71]

I’m sorry, but neuro is useless in this patient population unless you have to consult them for an EEG.

Depends heavily on your neurologists.

Mine run with the ball like champs for the anoxic brain folks. Frees me up to do a lot of other stuff that isn't long family meetings discussing imaging and prognosis.

 

[Bostonredsox]

Are y'all cooling out of hospital pulmonary arrests presenting with pea/asystole? 77y/o COPD'r on 4L, ran out of oxygen, decided to finish their cigarette before getting a new tank, arrests, family does 15 min of cpr until EMS gets their and takes over. come to hospital alive with total 20 minute downtime and completely comatosed. The data is not nearly as strong on the non VT/VF patients and at my smaller community shop we are questioning the immense amount of resources invested in to these pts, they are 1:1 RN until warmed and off nimbex with a huge nursing shortage, given the reduced benefit in the data

 

[SurfingDoctor]

Are y'all cooling out of hospital pulmonary arrests presenting with pea/asystole? 77y/o COPD'r on 4L, ran out of oxygen, decided to finish their cigarette before getting a new tank, arrests, family does 15 min of cpr until EMS gets their and takes over. come to hospital alive with total 20 minute downtime and completely comatosed. The data is not nearly as strong on the non VT/VF patients and at my smaller community shop we are questioning the immense amount of resources invested in to these pts, they are 1:1 RN until warmed and off nimbex with a huge nursing shortage, given the reduced benefit in the data

Respiratory arrests is the exact reason cooling is not standard of care in pediatrics. No effect on neurological outcomes.
Therapeutic hypothermia after out-of-hospital cardiac arrest in children. - PubMed - NCBI

Also true for in hospital arrests, and again primary respiratory in origin for children.
Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children. - PubMed - NCBI

Of course, children don’t have quite the degree of ischemic preconditioning that adults do, but they do have neuronal plasticity and so maybe those cancel each other out.

 

[nlax30]

Are y'all cooling out of hospital pulmonary arrests presenting with pea/asystole? 77y/o COPD'r on 4L, ran out of oxygen, decided to finish their cigarette before getting a new tank, arrests, family does 15 min of cpr until EMS gets their and takes over. come to hospital alive with total 20 minute downtime and completely comatosed. The data is not nearly as strong on the non VT/VF patients and at my smaller community shop we are questioning the immense amount of resources invested in to these pts, they are 1:1 RN until warmed and off nimbex with a huge nursing shortage, given the reduced benefit in the data

At my previous place when I first started fellowship we definitely were not. At least in the beginning we seemed to be pretty strict on out of hospital VT/VF arrest and cooled to 33C. As time went on we started including more post-arrests and moved to 36C. When I left it was on a case by case basis whether we cooled someone like your example. If we did it was just to 36C.

 

[deleted547339]

Are y'all cooling out of hospital pulmonary arrests presenting with pea/asystole? 77y/o COPD'r on 4L, ran out of oxygen, decided to finish their cigarette before getting a new tank, arrests, family does 15 min of cpr until EMS gets their and takes over. come to hospital alive with total 20 minute downtime and completely comatosed. The data is not nearly as strong on the non VT/VF patients and at my smaller community shop we are questioning the immense amount of resources invested in to these pts, they are 1:1 RN until warmed and off nimbex with a huge nursing shortage, given the reduced benefit in the data

Ummmmmm....nimbex? You’re not doing that on everyone, right? Just uncontrollable shivering I hope.

But back to your question, no I would not cool that patient. I would aggressively control the temp and ensure the patient remains afebrile, but I wouldn’t cool.

 

[deleted547339]

Depends heavily on your neurologists.

Mine run with the ball like champs for the anoxic brain folks. Frees me up to do a lot of other stuff that isn't long family meetings discussing imaging and prognosis.

Mine say that patients with multiple, massive ischemic turned hemorrhagic strokes with subfalcine herniation, obstructing hydrocephalus s/p subocc crani and EVD and still worsening exam that now only has corneals has an “indeterminant prognosis” in front of the family, and that we just need to wait and see how things go.....

That literally happened today.

 

[nlax30]

Mine say that patients with multiple, massive ischemic turned hemorrhagic strokes with subfalcine herniation, obstructing hydrocephalus s/p subocc crani and EVD and still worsening exam that now only has corneals has an “indeterminant prognosis” in front of the family, and that we just need to wait and see how things go.....

That literally happened today.

We initially had the opposite problem where Neuro would speak to the family during the initially cooling period and essentially say there was no hope. We then had families ready to pull the plug as soon as they were warm and then had to talk to them about waiting a few days.

 

[Hernandez]

Are y'all cooling out of hospital pulmonary arrests presenting with pea/asystole?

No. I hate hypothermia with a passion, I don’t think it works, I hate the delay on giving these people a few days to wake up after the 240mg of versed they invariably get during the 24 cold time and it doesn’t work. So I don’t use hypothermia on anything other than out of house vifb/tach. I won’t use on in house arrest either given the recent data. So unless cards is gung Ho about it, 35 degrees is my target.

 

[Bostonredsox]

I agree with your premise. i think the data is extremely poor that it has impactful neurologic outcomes outside of the classic VT/VF 60 year old who gets rosc in the ed, goes right to the lab, gets the LAD opened, gets cooled and wakes up 3 days later. the data is strongest by a mile in those patients and essentially these are the only ones we have been cooling. interesting the 35 target as opposed to 32-34. our protocol is a bit antiquated i think, most are still being cooled to around 33. and as for Times question on the nimbex, ideally its only given for shivering. but its not a 24/7 closed unit and the night time hospitalist is useless in most of these patients so in general if one comes in they generally have been just checking the boxes on the protocol and most of them are on nimbex when i come in with no documentation from the nurse if they were ever at all having shivering issues