HYPOTHERMIA POST OOH ARREST

A PROPOSED ANWICU INITIATIVE

Raj Nichani

Blackpool Victoria Hospital

KNOWLEDGE Strengthen collaboration across the

region

Spread good practice

Develop on the tremendous potential that exists.

CHAIN OF SURVIVAL

THERAPEUTIC HYPOTHERMIA POST VF ARREST – THE EVIDENCE

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.

The 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.

How good are we with putting this evidence into clinical practice.

Do we achieve similar results outside the settings of RCT’s.

NATIONAL VARIATION IN COOLING PRACTICES

WHY THIS PROJECT? Audit of our practice in Blackpool

Good success with the use of therapeutic hypothermia

Outcomes

0

2

4

6

8

10

12

VF sur

vive

d

VF Die

d

died duringcooling

inadequatelycooled

not cooled

cooled

OUTCOMES All survivors were discharged with good

neurological recovery

QUESTIONS GENERATED What was everyone else doing across

the region/nationally with cooling?

Were basic minimum standards being achieved?

Was any particular method better/more eficient?

Were other hospitals having similar outcomes?

BOTTOM LINE Are patients being subjected to

unacceptable variations in practice?

Source of variation

Do these variations influence outcome?

WHAT STANDARDS Clear and defined Unequivocal

LANCS + CUMBRIA NETWORK PROJECT Key individuals met and agreed on basic

standards.

All 4 hospitals represented

Proforma and Database created

IDEAL STANDARDS – ILCOR

If a patient meets the criteria for cooling following cardiac arrest then this should be initiated as soon as possible and definitely within 6 hours of cardiac arrest.

Aim for a target core temperature of 32-34˚C

Core temperatures should be monitored continuously during cooling and re-warming

The duration of cooling should be for 24 hours from commencement of induced hypothermia and not when target temperature is reached.

Re-warming should be at a rate of 0.3-0.5 ˚C per-hour to 36.5˚C.

DATA COLLECTION Central database

Hopefully move to a Web based system

Data anonymised prior to submission , processed and fed back

Time to initiation of cooling

0123456789

10

hospitalA

HospitalB

HospitalC

HospitalD

hours

Target temp reached

0

1

2

3

4

5

6

7

8

hosp A hosp B hosp C hosp D

YES

NO

MEDIAN TIME TO TARGET TEMPERATURE

0

1

2

3

4

5

6

7

8

hospitalA

HospitalB

HospitalC

HospitalD

hours

RAISE THE STANDARD OF PRACTICE – FEEDBACK TO INDIVIDUAL UNITS

Feedback to hospital D

0123456789

10

JAN-MARCH

APR-JUN

JUL-SEPT

OCT-DEC

all hosptals

hospital D

POTENTIAL BENEFITS Clinically relevant

Collaborative Audit – Larger patient numbers

Trainee involvement

Potential to spread to other regions

Generating a large valuable local database of patients.

GENERATE VALUABLE DATA Tremendous source of useful data on

regional practices, patient outcome – Inform decision making.

Are we cooling non VF arrests / in hospital arrests

What is the outcome in a wider spectrum of post VF/VT patients?

Benefits vs Costs

Incentive for units to drive up their performance.

Funding of resources

Links with other networks -

The European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group

CONTRIBUTORS Dr Tom Owen Dr Rachel Markham Dr Dominic Sebastian Dr Alison Quinn Dr Tina Duff Dr Neil Moreland Dr Richard Morgan Dr Tom Hurst Dr Brendan McGrath