Transcript THERAPEUTIC HYPOTHERMIA FOR CARDIAC ARREST

THERAPEUTIC HYPOTHERMIA FOR
CARDIAC ARREST
USING PERFORMANCE TARGETS
Raghu Loganathan, MD, FCCP
Director, Medical ICU & Stroke Center
March 2010
Disclosures
• Nothing extraordinary in the case reports
• Use 2 case studies to describe successful
implementation of a new protocol
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Cardiac Arrest
Epidemiology
Out of Hospital
cardiac arrests
• 64% of all arrests
• 2 to 9% survive to discharge
• 1/ 3rd of survivors have
irreversible cognitive
dysfunction
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In-hospital cardiac
arrests
• 36 % of all arrests
• 18% survive to
discharge
ILCOR 2008 Circulation 2008; 118:2452-83
MILD THERAPUETIC HYPOTHERMIA
CLINCIAL STUDIES
• RCT’s
– Bernard S et al – NEJM 2002; 346(8)
– Holtzer M et al – NEJM 2002; 346 (8)
– Idrissi et al – NEJM 2001
• Other Designs
– Benson D et al – Anaes Analg 1959; vol 38
– Bernard S et al – Ann Emerg Med 1997; 33(2)
– Bernard S et al – Resuscitation 2003; 56(1)
• Meta-analysis
– Holtzer M et al – Crit Care Med 2005; 33(2)
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Summary of Landmark Trials
HACA
(European)
Bernard
(Australian)
Initial rhythm
VF or VT
VF
Pre ED Cooling
Target Temp
Hypothermia patients
Standard Rx Patients
No
32 to 33 C
136
137
Yes
33 C
43
34
Hypothermia duration
Morbidity Reduction
Mortality Reduction
24 hours
12 hours
ARR 16%, NNT 6
ARR 16%, NNT 4
ARR 14%, NNT 6
ARR 17%, NNT 6
NS
NS
Adverse events (sepsis,
arrhythmias & Bleeding)
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HACA study group, NEJM, 2002 & Bernard SA, NEJM 2002
MILD THERAPEUTIC HYPOTHERMIA
FDNY initiative
• Less than 15% hospitals are currently using
hypothermia in US
• Designated hypothermia centers
– Cardiac arrests triaged by EMS
• Model based on STEMI/ PCI centers &
Stroke Centers
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Case Study -1
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69 year old male progressively dyspenic for 5 days
EMS found him cyanotic
Initial PEA, followed by asystole and V fib
Intubated on the field
Downtime 26 minutes
PMH: HTN, COPD, CAD, Morbid Obesity
• Arrived in ED comatose, GCS 3T
• RLPAP 54 on ventilator
Case Study -1
• Cold saline: 4.5 liters started within 5
minutes
• Surface cooling in 25 minutes
• Central line placed 30 minutes
• Initial Lactate was 9.3, ScVo2 65%
• Baseline Temp was 37.2
• Target temp reached in 3.4 hours
– Double vests used in series
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Case Study -1
• EKG: no STEMI
• Mild elevation of troponins
• ECHO showed depressed EF (30%) with
wall motion abnormalities
• CXR showed lower lobe infiltrates
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Case Study -1
• Posturing with de-cerebrating signs noted at 5
hours
• TH continued with sedation and paralytics for
shivering
• Re-warming after 24 hours
• EEG showed diffuse slowing, no seizures
• No clinical response when sedation was stopped
• Day 3; spontaneous eye opening and followed
some commands
• Day 6 Able to follow more commands
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Case Study -1
• Day 9: Unable to extubate transferred to
vent floor
• Day 17 Trach done
• Day 23 weaned off Trach
• Day 25 discharged to SNF
• March 25th: Trach de-cannulated,
ambulating and functioning at baseline
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Case Study : 2
• 72 year old male well known to Lincoln BIBEMS
• ESRD, Known asthma, Known CAD
• EMS called for respiratory distress, “noted to
hypotensive and dyspneic and went into cardiac
arrest”
• “Wide QRS on 3 lead” placed on NRB
• Subsequently “patient agonal, PEA on monitor, 3
blocks from hospital, CPR started immediately”
• ED arrival 10 minutes later: CPR continued
• Intubated in ED, various rhythms, 2 doses of
epinephrine and atropine given
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Case Study : 2
• Post intubation, noted to be “de-cerebrating” by ED
attending
• ROSC at 25 minutes: BP 143/ 76, RR 20 at set
rate and Pulse 67
• MICU called for therapeutic hypothermia
– Unresponsive to deep stimuli, comatose
• Hypothermia initiated 40 mins after ROSC
• Myoclonic jerks observed day 1
• 36 hours into protocol: patient opens eyes
and following simple commands
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Who to Cool?
Inclusion Criteria
• Post-cardiac arrest: defined as absence of pulses
requiring chest compressions, regardless of location or
presenting rhythm
• Any Initial rhythm (VF/VT, asystole or PEA)
• ROSC within 30 minutes to a SBP > 90 mmHg (with or
without vasoactive meds)
• Patient is comatose (unable to follow commands/ GCS <
6) upon arrival to the hospital in the absence of sedation
• RLTime at start of cooling is within 4 hours after ROSC
Who to Cool?
Exclusion Criteria
• Another reason to be comatose
• Purposeful response to verbal commands or
noxious stimuli after ROSC and prior to initiation of
hypothermia
• Absent brainstem function not explained by
treatment with sedatives, paralytics or anticholinergic agents
• A known terminal illness preceding arrest
• RL? Pregnancy ( Case report showing benefit)
Who to Cool?
Exclusion Criteria
• Pre-existing DNR and / or DNI code status and patient not
intubated as part of resuscitation efforts
• Multi-organ system failure, refractory shock requiring high
doses of vasopressors (MAP<60 on 2 or more vasopressor
agents), severe persistent hypoxia, acidosis or comorbidities with minimal chance of meaningful survival
independent of neurological status
• Uncontrolled bleeding to coagulopathy
• Recurrent VF or refractory VT in spite of appropriate
therapy should generate consideration of emergent referral
for cardiac catheterization
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Aa
Typical Cooling and Rewarming Protocol
Aa
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How to Cool?
ICU Notification
•
Once eligibility for induced hypothermia is
determined, call MICU/ Stroke attending ASAP
•
Obtain 2 large bore IV lines
•
Obtain baseline temperature
•
Infusion of approximately 2 to 3 liters (for 70 kg
individual) of normal saline refrigerated at 4-5 °C
–
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Can safely and reliably lower core body temperature by
3-4 °C when infused over 50 minutes.
COOLING PROTOCOL
• Obtain laboratory tests ASAP:
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Beta HCG on all women of childbearing age
Arterial blood gas
CBC/ platelets / PT / PTT/INR, Fibrinogen
Electrolyte “panel 7”, plus iCa / Mg / Phos , Cl-, Glucose
Amylase, Lipase, LFTs, , Lactate, CPK-MB, CK, Troponin
Blood Cultures, Urine Cultures, Urinalysis
• Toxicology screen if appropriate
• 12 lead EKG, Chest X-ray
• Placement of urinary catheter with temperature sensor
• RLInsertion of Central Line Catheter (subclavian or IJ)
HYPOTHERMIA BUNDLE
TIME ZERO
RETURN OF SPONTANEUOUS
CIRCULATION (ROSC)
10 MINUTES
COMPLETE SCREENING & NOTIFY ICU
ATTENDING
• “HYPOTHERMIA LABS” TO BE SENT
OUT
• START COLD SALINE
PLACE CENTRAL LINE IN SUBCLAVIAN
PLACE TEMP SENSING FOLEY
15 MINUTES
30 MINUTES
45 MINUTES
4 HOURS
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START SURFACE COOLING
ACHIEVE TARGET TEMP OF 32 C
GAYMAR III
Not selling this product
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January 2009 to February 2010
58 cardiac arrest patients to ED
22 patients in ED with ROSC
14 PATIENTS COOLED
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18 INPATIENTS
screened
12 INPATIENTS COOLED
Clinical Characteristics
• 26 patients cooled
• Rhythm:
– Vtach/ Vfib = 3 patients
– Asystole/ PEA = 18
– Mixed (VF with asystole/ PEA) = 5 patients
• Average APACHE II = 26 (predicted death rate of
64%)
• 22/ 26 had 100% compliance with hypothermia
bundle
• RL Average ICU days on vent 7.03 days
OUTCOMES
• 26 patients cooled
• 11/ 26 (42.3%) survived to hospital discharge
• 10/ 26 (38.4%) had “good outcomes”
CPS
category
Description
Number
1
Conscious and alert with normal function or
only slight disability
8
2
3
4
5
Conscious and alert with moderate disability
2
1
0
15
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Conscious with severe disability
Comatose or persistent vegetative state
Brain dead or death from other causes
OUTCOMES BY RHYTHM
Rhythm
Cooled
Survived
VF/ V-tach
3
1 (33.3%)
Asystole / PEA
18
8 (44.4%)
Mixed (VF/ V-tach
and asytole / PEA)
5
2 (40%)
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Summary of Studies
Neurologic
50% vs 14%
Neurologic
23% vs 7%
Survival
50% vs 23%
Survival
54% vs 33%
Neurologic
49% vs 26%
Neurologic
55% vs 39%
Survival
48% vs 32%
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Survival
59% vs 45%
Who to Cool ?
Does Rhythm Matter?
• Data from RCTs”
– Suggest VF and VT
• Combination of rhythms during a cardiac arrest
event
• Underlying mechanisms of brain injury are same
• Multiple observational trials on asystolic rhythm
have shown benefit
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Who to cool?
Do Circumstances of Arrest Adequately Predict Outcome?
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Practice Parameters: Prediction of outcome in comatose survivors
after cardiopulmonary resuscitation, NEUROLOGY 2006;67:203–210
Complications
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HACA study group, NEJM, 2002
SUMMARY
• Screening of patients:
– Judgement improves with time
– Rhythm alone should not exclude patients
• Most have combined rhythms
• Information on initial rhythm not always available
• Use of bundles helps with rapid
implementation and achieving target temp
– Performance targets helps
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FUTURE DIRECTIONS
• Phase 2 FDNY hypothermia
– Cool Enroute to hospital
• MCA ischemic Infarcts
• Traumatic brain injury
• SAH patients with increased ICP
• Hepatic encephalopathy
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Old CPR
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HYPOTHERMIA
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