post-cardiac arrest targeted temperature … · post-cardiac arrest targeted temperature management...

POST-CARDIAC ARREST TARGETED TEMPERATURE MANAGEMENT

(THERAPEUTIC HYPOTHERMIA)

CVICU CLINICAL PRACTICE GUIDELINES Vanderbilt Heart and Vascular Institute

Vanderbilt University Medical Center

Revised and Approved: February 2017

PURPOSE: To provide multidisciplinary care guidelines for initiation and management of patients

requiring post-cardiac arrest targeted temperature management (TTM).

INCLUSION CRITERIA

Cardiac arrest with primary cardiac etiology (including nonshockable rhythms)

Ability to initiate protocol within 6-12 hours of return of spontaneous circulation (ROSC) after a

suspected cardiac arrest

Age 18 years or older

Unresponsive patient not following commands after ROSC; brainstem reflexes (cough, gag,

corneal) and pathologic/posturing movements are permissible

Estimated time from arrest to ROSC less than 60 minutes

EXCLUSION CRITERIA

Arrest from a non-cardiac etiology

Unwitnessed arrest with initial nonshockable rhythm with a suspected prolonged downtime

Awakes spontaneously with purposeful movement; following commands

Known pregnancy

Initial temperature less than 93.2oF (34oC)

Known terminal illness

Recent major head trauma or traumatic arrest

Other causes of coma (drug intoxication, pre-existing coma prior to arrest)

Patients with known bleeding diathesis or ongoing bleeding

SERVICE

Patients are admitted to the CCU Service

Exception: Patients already on the cardiac surgery service remain on that service.

All targeted temperature management patients should receive Intensivist and Palliative Care

consults.

All patients with unwitnessed arrest with possible fall or chin impact and all witnessed arrests with

fall or apparent injury should receive Trauma consults.

HANDOVERS

When a “Code Ice” (non-STEMI) patient is admitted to the ED, the CCU Fellow or his/her designee

goes to the ED to assist with determination of immediate Cath Lab need and to receive handover

report from the ED physician. (See page 10 admission algorithm.)

Post Cardiac Arrest Targeted Temperature Management: CVICU Clinical Practice Guidelines (Revised: 2/2017)

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If a patient is to be admitted to the ED for head and neck traumagram, Cardiac Access center

personnel provide report to the ED Clinical Staff Leader (CSL). If the patient is to be admitted to

the Cath Lab or CVICU, report is provided to the CVICU CSL.

INITIATION AND MANAGEMENT OF TARGETED TEMPERATURE MANAGEMENT (TTM)

1) Cooling/Decooling

Monitor two core temperatures

o Preferential site order: Pulmonary artery > Bladder > Esophageal > Rectal

(Bladder temperature can be used in the presence of oliguria/anuria)

o One core temperature source is interfaced to the temperature management system

Cool to target temperature of 33oC as quickly as possible; a temperature range of 32o-36o is

acceptable.

Arctic Sun is the preferred method of temperature management.

If resistant to initial cooling, i.e., not at 36o in one hour or temperature increasing despite

cooling efforts, may facilitate cooling by:

o Administration of up to 2 liters of room-temperature or chilled NS.

- If chilled NSS is used, do not infuse via central line.

o Temporary addition of supplemental ice packs (with skin barriers)

Keep at target temperature until 24 hours after time of initial cardiac arrest.

Rewarm at 0.25oC/hour.

If cooling was initiated in an outlying hospital or in the field and patient is not considered a

candidate for TTM, may rewarm after consultation and approval by CCU attending. (See page

8, “Withdrawal Guidelines When Discontinuation Determinations Are Made after Therapy

Initiation.)

Temperature is maintained at 37.5oC or below for 72 hours after the initial arrest event.

o Acetaminophen 650mg every 6 hours X 6 doses is given unless contraindicated due to liver

dysfunction.

- First dose is administered at the first standard scheduled administration time following

admission.

- Given rectally until the patient’s temperature is 36 degrees; remaining doses can then

be given rectally, per tube, or PO.

o The Arctic Sun System remains on with a target temperature setting of 37o for 12 hours

after normothermia is achieved.

o Temperature management with the Arctic Sun System is usually discontinued 12 hours

after rewarming/normothermia, but the pads are not removed until it is determined that

the patient can remain normothermic without assistance.

o If temperature increases above 37.5o within the 72 hour, post-event timeframe,

temperature control with the Arctic Sun System or with standard cooling blankets is

reinitiated and used as tolerated. If shivering occurs during this phase of therapy, anti-

shivering measures such as extremity counterwarming or Demerol are considered.


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2) Hemodynamic Monitoring

Arterial Line

o All patients – as soon as possible

o Preferential sites: radial > femoral > axillary > brachial. (Axillary and brachial insertions

should be considered after CCU attending consultation)

o Procedural sheaths should be removed as soon as an alternate arterial access can be

established and when the ACT is less than 180.

o PA Catheter / Central line

o All patients should have a central line.

o PA Catheter is standard unless CCU Attending or Intensivist says not needed.

o Recommended PA catheter placement time - as soon as possible after admission (cold is

pro-arrrhythmic)

o ECHO for evaluation of myocardial function

o Transthoracic ECHO ASAP after admission

o If LV or RV function is abnormal, follow-up transthoracic ECHO 24 hours after first ECHO

o If hemodynamically unstable or not achieving end points of resuscitation, contact the CCU

attending with choices of repeat transthoracic ECHO, TEE probe placement, or PA catheter

placement.

Hemodynamically Unstable: Norepinephrine greater than 15 mcg/min and or addition of second

inotrope or vasopressor

Endpoints of Resuscitation: Urine output greater than 0.5mL/kg/hour, normal lactate, base deficit

less than or equal to - 4, SvO2 greater than 65% while warm and 75% while hypothermic.

(CI is unreliable measure during hypothermia and should be interpreted with caution. Many end

points of resuscitation are skewed during TTM. Attending Cardiologist and Intensivist guidance

should be sought to aid in hemodynamic interpretation.)

3) Hemodynamic Management

BP target: systolic BP > 90 and MAP > 65 until rewarming is complete

Norepinephrine is the preferred initial vasopressor

Nicardipine – initiate if SBP greater than 180 / titrate to SBP no lower than 150 (may be self

regulating for neuro protective)

Avoid hypovolemia – hypothermia can induce diuresis

Undefined Hypotension

o Norepinephrine = vasopressor of choice

o CVP is an appropriate management adjunct – if used in combination with ECHO results

- CVP less than 12 mmHg and normal biventricular function – fluid resuscitation

- CVP greater than 12 mmHg - management should be guided by ECHO and, if desired,

PA catheter


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Bradycardia with hemodynamic effects

o Consider changing target temperature from 33o up to 36o C and/or adding chronotrope

(Dopamine, Dobutamine, Epinephrine).

o Changes to target temperature are done in one degree increments. Effects are assessed

after each degree change to determine the need for further target adjustment. Changes

are made no faster than 0.5oC per hour.

Osborne waves and or QT-prolongation

o May occur during hypothermia - do not require specific treatment

Cardiogenic Shock

o STEMI

- Immediate attending notification

- Consider the need for mechanical cardiac support

- Norepinephrine for BP support (target MAP > 65)

o NON-STEMI

- Immediate attending notification

- Consider the need for mechanical cardiac support

- Norephinephrine for BP support

- PA catheter, ECHO, and endpoints of resuscitation will be used to decide if inotrope is

needed. Primary inotrope is dependent on physiologic objectives.

- If bradycardic, consider changing rewarming changing target temperature from 33o to

34o and/or chronotrope (Dopamine, Dobutamine, Epinephrine)

Vasoplegic or Distributive Shock

o Fluid resuscitation to a CVP of 12 if normal ventricular function by ECHO.

o Norepinephrine to dose of 15 mcg/min; then add vasopressin .04 units/min to maintain

BP. (Norepinephrine can continue to be titrated upward after vasopressin addition.)

4) Sedation, Comfort, Paralysis

Propofol infusion. Begin at 10 mcg/kg/min; titrate to BIS of 40 – 60. If BIS is less than 40,

decrease propofol to 10 mcg/kg/min unless a physician order is received to increase dose

(increased dose may be indicated for seizure treatment). Sedation should not be discontinued

while neuromuscular blockers are being administered.

If propofol is not hemodynamically tolerated (i.e., pressor needs increase), change to

midazolam for sedation. Begin midazolam infusion at 2 mg/hr or as ordered. Titrate to BIS of

40 – 60. If changed to midazolam, continue fentanyl.

Fentanyl infusion at 100 mcg/hr – ONLY IF a secondary reason for pain is present (examples:

trauma, rib fractures). No fentanyl titration without a physician order.

Vecuronium bolus – 0.1mg/kg IV (if not already paralyzed) or per orders; then cistatracurium

infusion. Begin cisatracurium at 2 mcg/kg/min – titrate to 1-2/4 train of four (TOF) twitches or

for shivering.


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Q1 hour TOF monitoring with target of 1-2/4 twitches until neuromuscular blockade is stopped.

(Due to hypothermia, maximum nerve stimulator output will likely be required.)

Discontinue neuromuscular blockade when patient’s temperature reaches 36OC.

Begin to wean sedation and fentanyl when TOF is 4/4, patient is breathing over the ventilator

or per order.

5) Shivering or Suspected Shivering

During the Cooling and Rewarming Therapy Phases

o May initiate counterwarming of extremities using the Bair Hugger

o Increase infusion rate of neuromuscular blocking agent

During the Post-Rewarming, Normothermia Maintenance Phase

o May initiate counterwarming of extremities using the Bair Hugger

o Consider Demerol

6) Neurologic Assessment and Care (including Trauma)

All non-STEMI and STEMI patients with unwitnessed arrest or suspected trauma should receive

a head and neck CT on admission prior to TTM. Ideally, patients arriving from outside

hospitals or facilities are routed through the ED for these head/neck traumagrams.

Exception: If STEMI changes are present, the CCU Attending or on-call Interventionalist can authorize

ED/traumagram bypass and have the patient admitted directly to the Cath Lab.

Per Level One Trauma Center standards, Trauma consults are ordered for all patients with:

1) Unwitnessed arrest with possible fall or chin impact

2) Witnessed arrests with fall or apparent injury.

Cervical collars are placed and C-Spine precautions are utilized for all patients with

unwitnessed arrests or arrests with fall.

o POSITIVE NECK CT:

- Do not place pillows under the head

- Log roll turns with head holds

- Head of bed may be elevated

o “NEGATIVE” NECK CT:

- A normal neck CT scan alone does not “clear the spine”. CT cannot detect ligament

injuries. Collars remain in place until cleared by the spinal cord service. The clearance

procedure requires active patient participation.

- With properly-placed collar, may be turned without head holds

- Head of bed may be elevated

o NO NECK CT RESULTS: Treat as positive until cleared

Seizure Monitoring and Interventions

o Seizure assessment is accomplished through physical assessment, burst activity on BIS,

heat generation on the Arctic Sun*, or EEG

o Continuous EEG monitoring is ordered for all TTM patients in the CVICU.


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- EEG monitoring can be ordered (for this patient group only) without first initiating a

Neuro Consult.

- EEG monitoring starts as soon as possible and is continued for 24 hours after

rewarming if the patient remains unresponsive. Video-EEG orders have a 24 hour

duration, so a new EEG order must be entered every morning until rewarming is

complete (patient awake and responsive) or to cover the 24 hours after rewarming if

the patient remains unresponsive after normothermia is reached.

- EEG results are remotely monitored and the Neuro team contacts the Primary team if

seizure activity is diagnosed. The primary team can then initiate a Neuro consult for

seizure management guidance.

- Official EEG reports are present in the electronic record.

o If seizures are present or suspected:

- Give 1000 mg levetiracetam IV and 1 mg lorazepam IV

- Consider an increase in the propofol or midazolam infusion rate and/or a 2 mg

midazolam IV bolus.

- Consult Neurology (do not wait until rewarmed)

- Give 500 mg levetiracetam IV BID until Neurology management recommendations are

received.

*Heat generation indicators in the Arctic Sun include cyclic up arrows on the panel and prolonged

low water temperatures. Assessment must be done to determine if the “unexpected” heat

generation is from shivering, seizures, or infection.

7) Neuroprognostication

While the TTM protocol can be discontinued at any time based on clinical conditions and

knowledge of the patient’s wishes, the earliest time for prognostication using clinical

examination in patients treated with TTM, where sedation or paralysis could be a confounder,

may be 72 hours after rewarming.

At greater than 72 hours post-arrest, the presence of status myoclonus and the absence of

pupillary reflexes are associated with poor neurologic outcomes.

At greater than 72 hours post-arrest, consider obtaining somatosensory evoked potentials

(SSEPS) in unresponsive patients. Absent N20 is predictive of a poor outcome.

In unresponsive patients at 72 hours post-arrest, consider neurologic consultation to determine

the utility of brain imaging for prognosis.

8) Oxygenation / Ventilation / Acid-Base

Oxygenation / Ventilation

o Avoid both hypoxia and hyperoxia

o Monitor non-temperature corrected ABGs Q 6 hours X 4 and PRN until normothermic.

o Continuous SpO2 monitoring

o Titrate pH 7.35 – 7.40 (May allow lower pH if metabolic acidosis is present.)


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o Target PaO2: 80 – 150 / Target pCO2: 32- 48

o If FiO2 is greater than 0.40, titrate FiO2 down until SpO2 drops below 100. Do not decrease

FiO2 below 0.40.

Unexplained lactic/metabolic acidosis may occur during hypothermia.

9) Electrolytes / Glucose

Potassium

o Monitor on admission, Q 6 hours X 4, and PRN

o Anticipate hypokalemia during hypothermia

o Do not treat unless level is below 2.8 mEq/L or arrhythmias are present

Magnesium

o Monitor on admission and PRN

o Target: 2 mEq/L or greater

o If below target, give magnesium sulfate 4 grams IV

Glucose

o IV insulin infusion to achieve target glucose of 120 – 180 until rewarmed. Glucose

monitoring Q1 Hour until rewarming is complete.

o No fingerstick glucose checks while hypothermic

10) Prevention of Secondary Complications

Stress ulcer and DVT prophylaxis

Urine analysis with reflexive culture on admission.

11) Nutrition / Medications

Due to the combined presence of hypothermia; narcotic, neuromuscular blocker and sedative infusions; and post-arrest hypoperfusion or shock, nutrition is not started until after rewarming.

No medications should be given IM or SQ until normothermic.

Clopidogrel, prasugrel, and ticagrelor are the only medications that should be given NG while hypothermic.

Aspirin and acetaminophen may be given rectally.

Medications like mannitol that are labeled “do not refrigerate” should be avoided.

12) Family Care

Palliative Care Consult on admission – regardless of the expected outcome

Educate family on the following:

o Indications and rationale for TTM

o Indications and rationale for sedation and paralytics

o Effects of induced hypothermia on body systems and measures implemented to support

or protect body systems

o Length of time patient will be cooled

o Risks associated with rewarming and steps taken to support patient during rewarming


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13) Withdrawal Guidelines When Discontinuation Determinations Are Made After Therapy Initiation

See algorithm on page 8.

14) Admission Algorithms for STEMI on Ice and Code Ice

See algorithms on pages 9 and 10.

Withdrawal Guidelines When Discontinuation Determinations

Are Made After Therapy Initiation

PATH ONE PATH TWO PATH THREE

Additional clinical information is obtained

and it is determined that TTM is contraindicated or

not appropriate.**

Additional information is obtained identifying care futility

OR Family communicates patient or family

wishes with request for therapy cessation and care withdrawal or comfort care

only. AND

It has been determined that the patient is a candidate for organ donation or the

TDS evaluation or TDS/family conversations are still in progress.

Additional information is obtained identifying care futility

OR Family communicates patient or family

wishes with request for therapy cessation and care withdrawal or comfort care only.

AND It has been determined that the patient is

not a candidate for organ donation.

Regardless of current temperature and therapy time, rewarming is begun at protocol rate of 0.25

o/hour.

TTM protocol interventions are applied until normothermic.

** SEE POST-CARDIAC ARREST

TARGETED TEMPERATURE

MANAGEMENT:

CVICU CLINICAL PRACTICE

GUIDELINES FOR LIST OF THERAPY

INCLUSION/

EXCLUSION CRITERIA.

Regardless of current temperature and therapy time, rewarming is begun at protocol rate of 0.25

o/hour.

TTM protocol interventions are applied until normothermic. Once normothermia is achieved, TDS evaluations are completed and donor protocols are begun or care withdrawal is performed per usual protocols. If, at any time in the rewarming process,

the determination is made that the

patient is not a candidate

for organ donation, switch to Path 3.

Neuromuscular blockers and Temperature Management system (Arctic Sun) are discontinued (i.e. passive rewarming). If the patient is not already on Fentanyl, Fentanyl infusion is considered for comfort. Prior to ventilator support withdrawal, neuromuscular blockade must be gone.

The Intensivist or Critical Care Fellow on the CVICU Service is consulted to determine if reversal of the paralytic agent is indicated when the patient has at least 1/4 twitches (paralytic reversal cannot be done at 0/4 twitches). The Intensivist or CC Fellow can administer reversal agents AND provide direction for the possible need for subsequent, timed doses of Glycopyrolate and Neostigmine.

When TOF assessment nets 4/4 twitches (through elimination or reversal), care withdrawal is performed or comfort care is initiated per usual protocols – regardless of temperature.


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Cervical Collar Clearance Protocol

Oversight: Spine Center Physicians (Orthopedic/Neurosurgery Spine)

Trauma Program Operational Process Performance (03/29/2017) Multidisciplinary Trauma Conference (03/29/2017)

Vanderbilt University Medical Center Division of Trauma, Emergency Surgery, and Surgical Critical Care

Last Revised: April 20, 2017

Revision Team Specialty Joseph M. Aulino, MD Radiology Tyler W. Barrett, MD, MSCI Emergency Medicine L. Taylor Davis, MD Radiology Angela L. Hatchett, RN, MSN, ACNP Spine Center Colin D. McKnight, MD Radiology Jacob P. Schwarz, MD Neurosurgery Spine Rebecca A. Reynolds, MD Neurosurgery Spine Mayur B. Patel, MD, MPH Trauma Austin Smith, MD Emergency Medicine

Definitions Hyperreflexia, defined by any of the following:

1.  Positive Babinski sign 2.  > 2 beats of clonus 3.  Positive Hoffman’s reflex

•  Upper motor neuron lesion from cord compression •  Is elicited by flipping either the volar or dorsal surfaces of the middle

finger & observing the reflex contraction of the thumb and index finger NEXUS (National Emergency X-Radiography Utilization Study) Criteria, defined by any of the following:

1.  Midline C-spine tenderness to palpation 2.  Altered mental status 3.  Intoxicated 4.  Abnormal neurologic exam 5.  Distracting injury

Abbreviations AS, Ankylosing Spondylitis C-collar, Cervical Collar C-spine, Cervical Spine DISH, Diffuse idiopathic skeletal hyperostosis ED, Emergency Deparment NP, Nurse Practitioner

VUMC C-Collar Clearance: ED patients and Inpatients Neurologically Normal Patient

Does patient have Any of the following: Unable to flex/extend?

Unable to rotate? ≥1 NEXUS criteria ?

Obtain CT C-spine without contrast

No acute abnormality Normal alignment, No fracture

No evidence of AS or DISH


Evidence of AS or DISH

Obtain & Label Upright AP/Lateral X-rays of the C-spine (including T1)

while in C-collar

Remain in C-collar Repeat Uprights (2 weeks) NP Spine Clinic (2 weeks)

Consult Spine

Acute abnormality (Positive fracture and/or

abnormal alignment) Unclear findings

Remove C-collar

YES NO

WITH HYPERREFLEXIA WITHOUT

HYPERREFLEXIA

UPRIGHT ABNORMAL

UPRIGHT NORMAL

Intubated patient without planned extubation in 48 hours

VUMC C-Collar Clearance: Intubated Patients

Consult Spine Obtain CT C-spine without contrast

Does patient have Any of the following: Cannot move all extremities antigravity?

Asymmetrical extremity strength ? Hyperreflexia? No rectal tone?


No evidence of AS or DISH


Evidence of AS or DISH

Acute abnormality (Positive fracture and/or

abnormal alignment) Unclear findings

Obtain MRI C-spine without contrast Remove C-collar

No MRI acute abnormality Normal MRI alignment

No fracture on MRI

YES NO

Placing NP Spine Clinic Appointments in WizOrder: •  Type in “Central appointment” •  Click “1. f/u appointment, post dc (using central appointment

scheduling) •  Fill out the form with the following:

§  Clinic name: Neurosurgery §  Provider name: NP spine clinic §  Timeframe: 2 weeks §  Diagnosis: C-collar clearance, hospital follow-up §  Comments: Prior to appointment, Patient needs AP/lateral X-

Rays of the cervical spine in collar §  CAS can reach team with questions at: 615-875-5100

Note: For outpatient NP Spine Clinic appointments, all Trauma Patients will be seen with or without prior inpatient Spine consultation (i.e., cervical collar patients cannot be refused outpatient spine appointments) Note: For Emergency Department patients, the Emergency Department Case Manager can assist with this scheduling

Key References: •  Patel MB, Humble SS, Cullinane DC, Day MA, Jawa RS, Devin CJ,

Delozier MS, Smith LM, Smith MA, Capella JM, Long AM, Cheng JS, Leath TC, Falck-Ytter Y, Haut ER, Como JJ. Cervical Spine Collar Clearance in the Adult Obtunded Trauma Patient: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma. 2015;78(2):430-441.

•  Badhiwala JH, Lai CK, Alhazzani W, et al. Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review. Ann Intern Med. 2015;162(6):429–437.

•  Bush L, Brookshire R, Roche B, et. al. Evaluation of Cervical Spine Clearance by Computed Tomographic Scan Alone in Intoxicated Patient with Blunt Trauma. JAMA Surg. 2016;151(9):807-813.

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