1. Therapeutic Hypothermia
Robert Dortman, Steven Lucynski, & Lauren Wynder

2. Objectives After this presentation, the audience will be able to...
1. Identify indications for Therapeutic Hypothermia (TH)
2. Discuss contraindications for TH
3. Identify the complications & risks of TH
4. Address the nursing management of TH

3. Indications Cardiac arrest* Stroke Neonatal encephalopathy
Spinal cord injury
PIC

4. Significance
Improves neurological outcomes in post-cardiac arrest by decreasing cellular metabolism and oxygen demand
Collaborative life-saving intervention

5. Nursing research
Aim: to determine adherence and barriers to Therapeutic Hypothermia for out of hospital cardiac arrest patients
Type of study: Retrospective chart audit over 12 months
Results:
33 patients met inclusion criteria
Only 4 at the goal temperature of C in target time of 2 hrs
17 not cooled at all
Length of time prior to cooling varied = <1 hr (n=15)- >3 hr (n=5)
9 cooled for recommended time; 18 cooled to target temperature; 9/18 consistent with guidelines
Implications: Poor education on management --->regular education sessions. Ready access to cooling agents
Adherence to therapeutic hypothermia guidelines for out-of-hospital cardiac arrest.

6. Types Invasive: cooling catheters, cooled blood and saline fluids
Non-invasive: cooling blankets, cooling caps, ice packs, Arctic Sun
Phases:
1. Cooling
2. Maintenance
3. Rewarming
Cooling—target temperature degrees Celcius within 6-12 hours
Maintenance—
Rewarming—According to the American Journal of nursing, research indicates that rewarming should be initiated hours after targeted temperature is achieved, unless ordered by MD . It should be done slowly… 0.5 degrees celcius per hour to reach degrees celcius…this research states that ”rapid rewarming reduces the benefit of therapeutic hypothermia”

7. When to initiate therapy
Within 12 hours of the return of spontaneous circulation post cardiac arrest
Preferred within 6 hrs, must be initiated by physician
PIC

8. Patient prep
Begin sedation after decision for TTM has been made (goal: RASS -5)
Arterial line and CVP line inserted
Labs drawn
Place temp probe x2 no oral/axillary
Skin assessment (esp posterior)
Lowest room thermostat temperature
Propofol is preferred agent due to neuro-protective effects
Richmond agitation sedation scale goal = -5 - deep sedation/unarousable
Aline/CVP line Should be inserted prior to cooling, otherwise difficult to place

9. Arctic sun Non-invasive TTM system
Pads are placed around patient’s legs and torso
Pads circulate water that can cool and rewarm patients
Can control body temperature within 0.2°C

12. Inclusion criteria ET intubated & ventilated
Arrived at facility within 6 hours & pulseless for less than 1 hour
Resuscitated from cardiac arrest with an initial rhythm of VF, pulseless VT, pulseless electrical activity, or asystole
GCS score <8
Hemodynamically stable (with or without vasopressors)

13. Exclusion criteria ◦Pregnant women ◦DNR and/or DNI ◦Sepsis
◦Significant trauma
◦Uncontrolled bleeding
◦Recent surgery
◦Severe bradycardia
◦Intracranial hemorrhage

14. Complications & Management
◦Prolonged PT & PTT; clotting factors depressed: Monitor Labs and obtain
blood cultures
◦Skin breakdown: Assess skin
◦Shivering: NMBA, tylenol/demerol and/or bair hugger
◦Cardiac dysrhythmias r/t K + Ca: IV fluid replacement therapy
◦Changes renal blood flow and reduces sodium absorption: Strict intake and
output monitoring
+Platelet functions are affected and there are prolonged PT and PTT; clotting factors are depressed making the patients at an increased risk for bleeding…..Monitor labs every 4 hours and obtain blood cultures every 12 hours after onset of cooling
+There is decreased blood flow to cooled areas, thus, the skin is at an increased risk for skin breakdown and pressure ulcers ---assess the skin for breakdown
+Shivering increases oxygen demand of tissue and cells…..Shivering can be managed with NMBA= Neuromuscular blocking agents, tylenol/demerol. Additionally, bair-hugger over the cooling pads can decrease shivering. Assessments should be done every1 hour
+Monitoring vital signs to include blood pressure and blood sugar checks. Monitor the heart rhythms for any dysrhythmias. These assessments should be done every 1 hour during the cooling and maintainence phases and every 30 minutes during the rewarming phase

16. Complications & Management
Changes renal blood flow and reduces sodium absorption: Strict intake and
output monitoring
Hyperglycemia: Glucose checks
Infection: Administer broad spectrum antibiotics, maintain aseptic technique
10% in study showed critical hypotension: Administer vasopressors PRN
+Water and electrolyte homeostasis are affected negatively and the patient is at a risk for cardiac dyshrythmias related to potassium and calcium. Thus initiate IV fluid replacement as needed. Replace potassium, calcium, and phosphorus electrolytes as needed; potassium is a commonly imbalanced electrolyte needing replacement
Changes renal blood flow and reduces sodium absorption...leading to increased urine excretion. monitor the urine output due to the potential for hypothermia induced diuresis
+Insulin levels decrease and there is increased insulin resistance leading to a risk for hyperglycemia. Thus, do glucose checks every 1 hours
+Maintain aseptic technique to prevent infection; obtain cultures and administer broad spectrum antibiotics if infection is suspected
+Administer vasopressors for hypotension as needed

17. Conclusion Objectives Met? Identified indications for TTM
Discussed contraindications for TTM
Identified complications and risks TTM
Addressed nursing management of TTM

18. Questions?

19. References
Boyce, R., Bures, K., Czamanski, J., & Mitchell, M. (2012). Adherence to therapeutic hypothermia guidelines
for out-of-hospital cardiac arrest. Australian Critical Care, 25(3),
doi: /j.aucc
Erb, J., Hravnak, M., Rittenberger, J. (2012). Therapeutic hypothermia after cardiac arrest. AJN, American Journal
of Nursing. 112(7),
Heard, K. J., Peberdy, M. A., Sayre, M. R., Sanders, A., Geocadin, R. G., Dixon, S. R., ... & O’Neil, B. J. (2010). A
randomized controlled trial comparing the Arctic Sun to standard cooling for induction of hypothermia
after cardiac arrest. Resuscitation, 81(1), 9-14
Muhammad Manasia, R. J., Husain, S. J., Hooda, K., Imran, M., & Bailey, C. (2014). Therapeutic Hypothermia
Post--Cardiac Arrest. Clinical Nurse Specialist: The Journal For Advanced Nursing Practice, 28(4),
doi: /NUR

20. Pirronen, K., Tiainen, M., Mustanoja, S., Kaukonen, K., Meretoja, A., Tatlisumak, T., & Kaste, M. Mild Hypothermia After Intravenous Thrombolysis in Patients With Acute Stroke: A Randomized Controlled Trial. Stroke, Presciutti, M., Bader, M. K., & Hepburn, M. (2012). Shivering Management During Therapeutic Temperature Modulation: Nurses' Perspective. Critical Care Nurse, 32(1), doi: /ccn Products (2014). In Arctic Sun Temperature Management System. Retrieved December 1, 2014, from Urden, L., Stacy, K., & Lough, M. (2014). Critical care nursing: Diagnosis and management (7th ed). St. Louis, MO: Elsevier Mosby.