MEDICAL CENTER / Title: Therapeutic Hypothermia
Section: Clinical
Dept of Origin:
ICU / Dept of Dist:
ED, ICU, Cath Lab
POLICIES & PROCEDURES / Reviewed/Revised:
9/07, 04/10, 1/12 / Approved:
PREAMBLE:
The Dignity Health facilities of the Central Coast develop and implement policies that seek to encompass our mission statement and core service values of Dignity, Stewardship, Justice, Collaboration, and Excellence in our daily service. Our policies guide us in supporting this ministry of providing quality, compassionate services.
POLICY: Therapeutic Hypothermia will be defined as the early recognition and prompt intervention and treatment after the return of spontaneous circulation (ROSC) post cardiac arrest. Utilizing the multidisciplinary team approach, appropriate resources and equipment will be provided for the patient meeting criteria.
Relative Inclusion Criteria:
· Non Traumatic Cardiac Arrest with ROSC
· Core Temperature > 33° Celsius at presentation
· Time to initiation of therapeutic hypothermia is less than 6 hours
· Comatose after ROSC: GCS less than 8, and no purposeful response to pain
May consider for other indications:
· hanging as suspected cause of cardiac arrest
· malignant hyperthermia
Relative Exclusion Criteria:
· Conflict with Advanced Medical Directives or DNR status
· Uncontrolled Bleeding (Absolute Contraindication)
· Cardiovascular instability as evidenced by: Uncontrollable arrhythmias
· Refractory hypotension (unable to achieve MAP of 60 mmHg despite interventions)
· Sepsis or other cause (as suspected cause of cardiac arrest)
· Suspected intracranial hemorrhage
· Major intracranial, intrathoracic, or intrabdominal surgery in past 14 days
· IVC filters (placement of intravascular cooling catheter should be IJ or subclavian NOT femoral if patient has an IVC filter)
PURPOSE: To provide guidelines for the application of mild therapeutic hypothermia to comatose survivors of cardiac arrest in an attempt to improve mortality and neurological outcomes.
BACKGROUND: Brain temperature during the first 24 hours following resuscitation from cardiac arrest may have a significant effect on survival and neurological recovery. Cooling to 32-34°Celsius for 24 hours may decrease the chance of death and increase the chance of neurological recovery.
EQUIPMENT:
· External cooling (Blanketrol III) machine is stored in ED and equipment storage room on Telemetry Unit.
Ø Surface cooling vests, head wraps, and blankets are stored in ED, ICU, and Materials Management
· Intravascular cooling (Alsius/Zoll Coolgard) machine is stored in the ICU.
Ø Foley and rectal probe cables (DO NOT DISPOSE) are stored with machine.
Ø Temperature sensing foley catheters and rectal probes are stored in Cath Lab, ICU, and Materials Management.
Ø Intravascular cooling catheters (Cool Line, Icy, and Quattro) are stored in the Cath Lab.
Ø Alsius/Zoll Start Up kit are stored in the ICU.
Ø 500ml bag normal saline available in Omni-cell.
· Re-usable equipment will be cleansed after each patient use and per Equipment, Patient Care Item Policy.
PROCEDURE:
PROCEDURE for Cold Saline Infusion:
· If core temperature is > 33°Celsius at initiation of protocol
· Bolus with cold (4°C / 39°F) of 0.9% NS (available in Emergency Department / Cath Lab) @ 30ml/kg over 30-60 minutes with a maximum of 2 liters total. This is NOT to be given via jugular or subclavian line; a peripheral or femoral line must be used.
PROCEDURE for External Cooling:
Obtain device and apply cooling blanket and/or vest to patient’s head, torso, and limbs.
· Insert temperature sensing device (foley, rectal, or esophageal probe)
· Set target temperature at 32°-34°C for 24 hours
· Observe skin every 2 hours for signs of breakdown
· *In cath lab/ED, may utilize ice packs (neck, axilla, and groin) to initially achieve cooling if blanket unavailable.
· Monitor labs/diagnostics as directed
PROCEDURE for Intravascular Cooling: Insert intravascular cooling catheter (Alsius) and connect to unit.
· Equipment:
Intravascular cooling catheter (see below for placement and dwell times for each)
Intravascular cooling start up kit (contains tubing and coil)
500 ml bag of NS
Catheter Name / Cool Line / Icy / QuattroModel Number / CL-2295 / IC-3893 / IC-4593
Number of Heat Exchange Balloons / 2 / 3 / 4
Number of Infusion Lumens / 3 / 3 / 3
Insertion Site / Subclavian
Internal Jugular
Femoral / Femoral / Femoral
Outer Diameter at Insertion Site / 9.3F / 9.3F / 9.3F
Length / 22cm / 38cm / 45cm
Flow Rate (ml/hr) **
Distal
Proximal
Medial / 2200
1400
1400 / 1900
1300
1000 / 1900
1300
1000
Dwell Time of Catheter / 7 days / 4 days / 4 days
** DO NOT USE POWER INJECTOR with intravascular cooling catheter**
· Check coolant level (additional coolant or distilled H2O in Biomed)
· Power on (follow prompts for system set up)
· Set target temperature at 33°C and rate as max (default) for 24 hours
· Open start up kit and place coil into coolant
· Secure coldwell lid and put air trap in its holder
· Open lid of roller pump
· Undo tubing bundle containing the spike. The largest section of tubing goes into the roller pump
· Manually rotate the pump to 11 o’clock position to facilitate loading of tubing
· Load tubing into pump (side of tubing with flange fits into the slot on the right side of the roller pump
· After spiking saline bag, lift out the air trap from its holder and turn it upside down.
· Press and hold the PRIME switch until the air trap and tubing are completely full of saline (approximately 2 minutes)
· Insert primary (temperature sensing foley catheter) and secondary (rectal or esophageal probe) temperature sensing device and connect to device.
· Monitor labs/diagnostics as directed
PROCEDURE for Re-WARMING:
If EXTERNAL Cooling utilized:
· Remove cool packs and blankets
· May apply warm blanket (do NOT use device to re-warm)
· Monitor labs/diagnostics as directed
If INTRAVASCULAR Cooling utilized:
· Set target temperature at 36°C and re-warming rate at 0.25°C/hour
· Monitor labs/diagnostics as directed
PROCEDURE for Intravascular Catheter Removal:
· RN or Physician may remove
· Use 10ml syringe to port and deflate balloons (leave port open once deflated)
· Manually remove venous line (may note some bumpy traction at balloon sites as line is removed)
· Hold manual pressure or utilize femo-stop as indicated to obtain hemostasis
References:
1) Advanced Life Support Task Force of the International Liaison Committee on Resuscitation (2003). Therapeutic Hypothermia after Cardiac Arrest. Circulation; 108: 118-121. Doll: 103.1016/j. resuscitation.2007.04.015
2) American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (2005) Circulation; 112:24.
3) Bernard, Stephen (2006). Therapeutics Hypothermia after Cardiac Arrest. Neurological Clinics; Vol24, No.1
4) Hypothermia after Cardiac Arrest Study Group (2002). Mild Hypothermia to Improve Neurological Outcomes after Cardiac Arrest. NEJM: 346:549-556
5) Stiell I.G., Wells, G.A. et.al. Advanced Cardiac Life Support in Out of Hospital Cardiac Arrest (2004). NEJM; 351:7:647-656
6) Society of Critical Care Clinical Focus Conference: Hypothermia: Keeping It Cool – How to Implement Hypothermia in Your Clinical Practice; April 2010; Pasadena, CA
7) Neurocritical Care [abstract] 2007; 6:228
8) Zoll Circulation: Thermogard XP/Coolgard 3000 Operation Manual , 2009
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