Therapeutic hypothermia - Revision history

ClaireLewis at 17:12, 26 September 2019

2019-09-26T17:12:09Z

← Older revision		Revision as of 17:12, 26 September 2019
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	**Reduces oxygen free radical production and lipid peroxidation		**Reduces oxygen free radical production and lipid peroxidation
	*Cooling to 32-34ºC in initial studies, current studies suggest 36ºC equally beneficial<ref>Nielsen N, et al. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. N Engl J Med. 2013; 369:2197-2206. DOI: 10.1056/NEJMoa1310519</ref>		*Cooling to 32-34ºC in initial studies, current studies suggest 36ºC equally beneficial<ref>Nielsen N, et al. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. N Engl J Med. 2013; 369:2197-2206. DOI: 10.1056/NEJMoa1310519</ref>
	~~ent~~ should be initiated immediately after ROSC		*Treatment should be initiated immediately after ROSC
	**Patient may be cooled concurrently with cardiac catheterization		**Patient may be cooled concurrently with cardiac catheterization
	*Cooling should occur prior to CT scan if there is need for intracranial pathology workup		*Cooling should occur prior to CT scan if there is need for intracranial pathology workup

ClaireLewis at 17:10, 26 September 2019

2019-09-26T17:10:57Z

← Older revision		Revision as of 17:10, 26 September 2019
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	==Indications==		==Indications==
	*~~V-fib~~ arrest		*[[Vfib]] arrest
	*Other pulseless dysrhythmias (relative)		*Other pulseless [[dysrhythmias]] (relative)

	==Contraindications/Exclusions==		==Contraindications/Exclusions==
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	*Glasgow Motor score >5		*Glasgow Motor score >5
	*Minimal pre-morbid cognitive status		*Minimal pre-morbid cognitive status
	*Unable to maintain SBP > 90 mmHg, with or without pressors, after CPR		*Unable to maintain [[shock\|SBP > 90 mmHg]], with or without pressors, after CPR
	*Other reason for coma		*Other reason for coma
	**Intracranial pathology (i.e. intracranial hemorrhage, ischemic stroke)		**Intracranial pathology (i.e. [[intracranial hemorrhage]], ischemic [[stroke]])
	**Subarachnoid hemorrhage		**[[Subarachnoid hemorrhage]]
	**Sedation		**[[Sedation]]
	**Drug overdose		**[[Drug overdose]]
	**Status epilepticus		**[[Status epilepticus]]
	*Sepsis as etiology for arrest		*[[Sepsis]] as etiology for arrest
	*DNR/DNI status, terminal illness		*DNR/DNI status, terminal illness
	*Uncontrollable bleeding or known bleeding diathesis with active bleeding		*Uncontrollable bleeding or known [[coagulopathy\|bleeding diathesis]] with active bleeding
	*Significant trauma (especially intra-abdominal)		*Significant [[trauma]] (especially intra-abdominal)
	*Pregnancy		*[[Pregnancy]]
	*Therapeutic hypothermia may be safe for postpartum cardiac arrest<ref>Song et al. Safely completed therapeutic hypothermia in postpartum cardiac arrest survivors. Am Jour Emer Med. June 2015. Volume 33, Issue 6, Pages 861.e5–861.e6.</ref>		*Therapeutic hypothermia may be safe for postpartum cardiac arrest<ref>Song et al. Safely completed therapeutic hypothermia in postpartum cardiac arrest survivors. Am Jour Emer Med. June 2015. Volume 33, Issue 6, Pages 861.e5–861.e6.</ref>

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	**Supplement with ice packs to groin, chest, axillae, neck until 34ºC reached		**Supplement with ice packs to groin, chest, axillae, neck until 34ºC reached
	*Prevention of shivering and paralysis		*Prevention of shivering and paralysis
	**Use benzodiazepines		**Use [[benzodiazepines]]
	**Paralytics only if needed, and ensure patient fully sedated		**Paralytics only if needed, and ensure patient fully sedated

	==~~Maintainance~~==		==Maintenance==
	===Sedation===		===[[Sedation]]===
	*Fentanyl ~~Injection~~ 50 mcg IV every hour as needed for pain		*[[Fentanyl]] bolus 50 mcg IV every hour as needed for pain
	*Fentanyl IV infusion NSS		*Fentanyl IV infusion NSS
	*Propofol IV infusion		*[[Propofol]] IV infusion
	*Lorazepam IV infusion		*[[Lorazepam]] IV infusion
	*Lorazepam ~~Injection~~ 1mg IV every 2 hours as needed for agitation		*Lorazepam bolus 1mg IV every 2 hours as needed for agitation
	===Shivering===		===Shivering===
	*Prevention of shivering is important to avoid warming and needless oxygen consumption		*Prevention of shivering is important to avoid warming and needless oxygen consumption
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	**Decrease plateau pressures		**Decrease plateau pressures
	**Hypoxemia is present		**Hypoxemia is present
	*Consider meperidine q2hrs<ref>Choi HA, Ko SB, Presciutti M, et al. Prevention of Shivering During Therapeutic Temperature Modulation: The Columbia Anti-Shivering Protocol. Neurocrit Care. 2011; 14(3):389-394.</ref><ref>Fox Chase Cancer Center. Therapeutic [[Hypothermia]]Protocol. University of Pennsylvania. https://www.med.upenn.edu/resuscitation/docs/protocols/FoxChaseCancerCenterTherapeuticHypothermiaOrderSetafterCardiacArrest-latestrevision8-4-11.doc</ref>:		*Consider [[meperidine]] q2hrs<ref>Choi HA, Ko SB, Presciutti M, et al. Prevention of Shivering During Therapeutic Temperature Modulation: The Columbia Anti-Shivering Protocol. Neurocrit Care. 2011; 14(3):389-394.</ref><ref>Fox Chase Cancer Center. Therapeutic [[Hypothermia]]Protocol. University of Pennsylvania. https://www.med.upenn.edu/resuscitation/docs/protocols/FoxChaseCancerCenterTherapeuticHypothermiaOrderSetafterCardiacArrest-latestrevision8-4-11.doc</ref>:
	**50mg for normal renal function		**50mg for normal renal function
	**25mg if CrCl < 30ml/min		**25mg if CrCl < 30ml/min
	*Pancuronium IV infusion		*[[Pancuronium]] IV infusion
	**Initiate before initiating cooling. Dosing recommendations: 0.1mg/kg loading dose followed by a continuous infusion of 0.33-2 mcg/kg/minute		**Initiate before initiating cooling. Dosing recommendations: 0.1mg/kg loading dose followed by a continuous infusion of 0.33-2 mcg/kg/minute
	**Do not use in patients with renal and/or hepatic insufficiency		**Do not use in patients with renal and/or hepatic insufficiency
	*~~Cisatricurium~~ for renal/hepatic impairment		*Cisatracurium for renal/hepatic impairment
	**0.2mg/kg IV bolus		**0.2mg/kg IV bolus
	**Followed by infusion at 1 mcg/kg/min, max of 3 mcg/kg/min		**Followed by infusion at 1 mcg/kg/min, max of 3 mcg/kg/min
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	*Head of bed at 30 degrees		*Head of bed at 30 degrees
	*Goal MAP 80 - 100 mmhg		*Goal MAP 80 - 100 mmhg
	**Titrate with norepinephrine (start 2-4 mcg/min) if EF > 50%		**Titrate with [[norepinephrine]] (start 2-4 mcg/min) if EF > 50%
	**Titrate with dobutamine (start 2.5-20 mcg/kg/min) if EF < 50%		**Titrate with [[dobutamine]] (start 2.5-20 mcg/kg/min) if EF < 50%
	**IV [[nitroglycerin]] starting at 10 mcg/min if hypertensive		**IV [[nitroglycerin]] starting at 10 mcg/min if hypertensive
	*Check skin q2-6 hrs for cold injury		*Check skin q2-6 hrs for cold injury
	*Maintain ~~normoglycaemia~~		*Maintain normoglycemia
	**Do not treat ~~hyperglycaemia~~ aggressively, as enzymatic functions are decreased at low temperatures, and rebound hypoglycaemia possible with rewarming		**Do not treat [[hyperglycemia]] aggressively, as enzymatic functions are decreased at low temperatures, and rebound hypoglycaemia possible with rewarming
	*Replete K, Mg, Phos, Ca (hypothermia induced diuresis is expected)		*Replete K, Mg, Phos, Ca (hypothermia induced diuresis is expected)
	*Common unconcerning ECG findings during cooling - Osborne wave, HR < 40 bpm		*Common unconcerning ECG findings during cooling - Osborne wave, HR < 40 bpm
	*Consider continuous EEG within 6 hrs, no later than 12 hrs after onset of cooling		*Consider continuous EEG within 6 hrs, no later than 12 hrs after onset of cooling
	*Stress dose steroids for adrenal insufficiency		*Stress dose [[steroids]] for adrenal insufficiency
	*Seizure prophylaxis		*?[[Seizure]] prophylaxis

	===Labs===		===Labs===
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	===Other Considerations===		===Other Considerations===
	*GI prophylaxis		*GI prophylaxis
	*Modify prophylactic heparin or ~~low molecular weight heparin~~ dosing as there is hypothermic coagulopathy<ref>Wahby KA et al. Heparin dosing in critically ill patients undergoing therapeutic hypothermia following cardiac arrest. Resuscitation. 2014 Apr;85(4):533-7.</ref>		*Modify prophylactic [[heparin]] or [[LMWH]] dosing as there is hypothermic coagulopathy<ref>Wahby KA et al. Heparin dosing in critically ill patients undergoing therapeutic hypothermia following cardiac arrest. Resuscitation. 2014 Apr;85(4):533-7.</ref>
	**No clear best way for monitoring of anticoagulation until further studies		**No clear best way for monitoring of anticoagulation until further studies
	**Consider modified dosing:		**Consider modified dosing:

Rossdonaldson1: Text replacement - "Troponin" to "Troponin"

2019-07-01T20:37:30Z

Text replacement - "*Troponin" to "*Troponin"

← Older revision		Revision as of 20:37, 1 July 2019
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	**Expect decreased K, Ca, Mg, Phos during, and rebound at rewarming		**Expect decreased K, Ca, Mg, Phos during, and rebound at rewarming
	**Hyperglycemia as metabolism slows at low temperature and body develops insulin resistance		**Hyperglycemia as metabolism slows at low temperature and body develops insulin resistance
	*~~Troponins~~, CK-MB q6 hrs x2 days		*[[Troponin]]s, CK-MB q6 hrs x2 days
	*Lipase, LFTs (if abnormal, no need to intervene unless persistent after rewarming)		*Lipase, LFTs (if abnormal, no need to intervene unless persistent after rewarming)
	*Other - Cortisol, UA, Pan-cultures, tox screen		*Other - Cortisol, UA, Pan-cultures, tox screen

Kxl328: /* Other Considerations */

2019-04-28T19:03:18Z

Other Considerations

← Older revision		Revision as of 19:03, 28 April 2019
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	*Modify prophylactic heparin or low molecular weight heparin dosing as there is hypothermic coagulopathy<ref>Wahby KA et al. Heparin dosing in critically ill patients undergoing therapeutic hypothermia following cardiac arrest. Resuscitation. 2014 Apr;85(4):533-7.</ref>		*Modify prophylactic heparin or low molecular weight heparin dosing as there is hypothermic coagulopathy<ref>Wahby KA et al. Heparin dosing in critically ill patients undergoing therapeutic hypothermia following cardiac arrest. Resuscitation. 2014 Apr;85(4):533-7.</ref>
	**No clear best way for monitoring of anticoagulation until further studies		**No clear best way for monitoring of anticoagulation until further studies
	**Consider ~~heparin~~ 40 units IV bolus~~, followed~~ by 7 u/kg/hr during TH with scheduled repeated coags, plus or minus heparin levels		**Consider modified dosing:
			***Heparin 40 units IV bolus
			***Followed by 7 u/kg/hr during TH with scheduled repeated coags, plus or minus heparin levels

	==Disposition==		==Disposition==

Kxl328: /* Imaging */

2019-04-28T19:02:21Z

Imaging

← Older revision		Revision as of 19:02, 28 April 2019
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	*Consider head CT		*Consider head CT
	*Consider CTPE study		*Consider CTPE study

			===Other Considerations===
			*GI prophylaxis
			*Modify prophylactic heparin or low molecular weight heparin dosing as there is hypothermic coagulopathy<ref>Wahby KA et al. Heparin dosing in critically ill patients undergoing therapeutic hypothermia following cardiac arrest. Resuscitation. 2014 Apr;85(4):533-7.</ref>
			**No clear best way for monitoring of anticoagulation until further studies
			**Consider heparin 40 units IV bolus, followed by 7 u/kg/hr during TH with scheduled repeated coags, plus or minus heparin levels

	==Disposition==		==Disposition==

Rossdonaldson1: Text replacement - " NTG " to " nitroglycerin "

2019-03-30T14:22:50Z

Text replacement - " NTG " to " nitroglycerin "

← Older revision		Revision as of 14:22, 30 March 2019
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	**Titrate with norepinephrine (start 2-4 mcg/min) if EF > 50%		**Titrate with norepinephrine (start 2-4 mcg/min) if EF > 50%
	**Titrate with dobutamine (start 2.5-20 mcg/kg/min) if EF < 50%		**Titrate with dobutamine (start 2.5-20 mcg/kg/min) if EF < 50%
	**IV ~~NTG~~ starting at 10 mcg/min if hypertensive		**IV [[nitroglycerin]] starting at 10 mcg/min if hypertensive
	*Check skin q2-6 hrs for cold injury		*Check skin q2-6 hrs for cold injury
	*Maintain normoglycaemia		*Maintain normoglycaemia

Rossdonaldson1: /* See Also */

2019-03-26T16:03:04Z

Rossdonaldson1: /* ABG Interpretation */

2019-03-26T16:02:50Z

ABG Interpretation

← Older revision		Revision as of 16:02, 26 March 2019
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	*Other - Cortisol, UA, Pan-cultures, tox screen		*Other - Cortisol, UA, Pan-cultures, tox screen

	===ABG Interpretation===		===[[ABG]] Interpretation===
	*Rewarm ABG to 37C for analysis (controversial)		*Rewarm ABG to 37C for analysis (controversial)
	*A warmed ABG from a hypothermic patient will show a higher PaO2, higher PaCO2, and a lower pH than that actually present in the patient’s blood ''in vivo''		*A warmed ABG from a hypothermic patient will show a higher PaO2, higher PaCO2, and a lower pH than that actually present in the patient’s blood ''in vivo''

SLuckettG: /* Other Concerns */

2019-02-28T00:05:24Z

Other Concerns

← Older revision		Revision as of 00:05, 28 February 2019
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	*Check skin q2-6 hrs for cold injury		*Check skin q2-6 hrs for cold injury
	*Maintain normoglycaemia		*Maintain normoglycaemia
			**Do not treat hyperglycaemia aggressively, as enzymatic functions are decreased at low temperatures, and rebound hypoglycaemia possible with rewarming
	*Replete K, Mg, Phos, Ca (hypothermia induced diuresis is expected)		*Replete K, Mg, Phos, Ca (hypothermia induced diuresis is expected)
	*Common unconcerning ECG findings during cooling - Osborne wave, HR < 40 bpm		*Common unconcerning ECG findings during cooling - Osborne wave, HR < 40 bpm

SLuckettG: /* Other Concerns */

2019-02-28T00:04:27Z

Other Concerns

← Older revision		Revision as of 00:04, 28 February 2019
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	**IV NTG starting at 10 mcg/min if hypertensive		**IV NTG starting at 10 mcg/min if hypertensive
	*Check skin q2-6 hrs for cold injury		*Check skin q2-6 hrs for cold injury
	*Maintain ~~tight BG control, 110-150mg/dL~~		*Maintain normoglycaemia
	*Replete K, Mg, Phos, Ca (hypothermia induced diuresis is expected)		*Replete K, Mg, Phos, Ca (hypothermia induced diuresis is expected)
	*Common unconcerning ECG findings during cooling - Osborne wave, HR < 40 bpm		*Common unconcerning ECG findings during cooling - Osborne wave, HR < 40 bpm

← Older revision		Revision as of 16:03, 26 March 2019
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	==See Also==		==See Also==
	{{[[Hypothermia]]Cardiac Arrest Links}}		{{Hypothermia Cardiac Arrest Links}}

	==References==		==References==

Therapeutic hypothermia - Revision history

ClaireLewis at 17:12, 26 September 2019

ClaireLewis at 17:10, 26 September 2019

Rossdonaldson1: Text replacement - "*Troponin" to "*Troponin"

Kxl328: /* Other Considerations */

Kxl328: /* Imaging */

Rossdonaldson1: Text replacement - " NTG " to " nitroglycerin "

Rossdonaldson1: /* See Also */

Rossdonaldson1: /* ABG Interpretation */

SLuckettG: /* Other Concerns */

SLuckettG: /* Other Concerns */

Rossdonaldson1: Text replacement - "Troponin" to "Troponin"