Effective Date:
august 2010 / Number:
7998
Originator:
Director, Cardiology
ORGANIZATIONAL POLICY
Therapeutic Hypothermia After Cardiac Arrest / CONCURRENCE:
Chair, Clinical Code Committee
Chair, Pharmacy and Therapeutics Committee
CNO/VP of Nursing
Director, Critical Care
Director, Emergency Services
Director, Neurosciences
Director, Respiratory Therapy
Director, Telecommunications
Medical Director, Emergency Services
Medical Director, Critical Care
Medical Director, Cardiology
Medical Director, Neurology
APPROVAL:
CEO/PRESIDENT
PURPOSE OF POLICY
This policy provides standard operational guidelines for patients requiring therapeutic hypothermia. Therapeutic hypothermia has been shown to decrease the chance of death and increase the chance of neurological recovery status post cardiac arrest, especially during the first 24 hours of the cardiac arrest event. It has also been shown to benefit neurology patients: stroke, subarachnoid hemorrhage, traumatic brain injury and closed head injury.
SCOPE
This policy applies to all patients receiving Therapeutic Hypothermia who meet the defined inclusion criteria. Patients receiving Therapeutic Hypothermia will be observed in a critical care setting (Emergency Department, Intensive Care Unit).
Inclusion Criteria post Cardiac Arrest:
1. Within 6 hours post cardiac arrest (initial rhythm of Pulseless VT or VF but may consider PEA and Asystole with return of spontaneous circulation (ROSC) and ≤ 1 hour resuscitation time)
2. Less than 15 minutes from collapse to CPR
3. Comatose after ROSC: GCS less than 8, and no purposeful movement to pain
4. ≥ 18 years of age
5. Women must have a negative BHCG test or are over 50 years old (may initiate hypothermia pending result. If result is positive discontinue hypothermia).
Absolute Exclusion Criteria:
1. Do Not Resuscitate Order (DNR) in Place
2. Active severe bleeding
3. Refractory shock with systolic blood pressure <90 despite fluids and vassopressors
4. Uncontrolled ventricular dysrythmias
5. Pregnancy
6. Coma unrelated to arrest
Relative Exclusion Criteria:
1. <18 years of age
2. Recent major surgery within 14 days
3. Systemic infection/sepsis
4. Audible rales/CHF
5. Known existing coagulopathy (Coagulopathy was a relative exclusion in the 2002 NEJM studies; communication with regional teaching hospitals supports the use of TH in patients on therapeutic anticoagulation and some hospitals only exclude on the basis of active hemorrhage).
6. Active Seizures
PROCEDURES
A. Ambulance to Ellis Process Flow:
1. Patient meets Therapeutic Hypothermia Criteria per EMS protocol
2. Contacts the Ellis Hospital Emergency Department and asks that a “Code Cool” be called
3. The Emergency Department Nurse and/or designee will dial 911 and will alert the Operator to call a “Code Cool,” also stating patient name, location (EMS) and estimated time of arrival. The “Code Cool” will notify E1, E2, ICU NM, Admitting, Supervisor and Respiratory Therapist
4. ICU staff begins to prepare for patients arrival, pending final identification as a Therapeutic Hypothermia patient when the patient arrives in the Emergency Department
5. Emergency Department Physician and/or designee will contact the ICU charge nurse as well as the Critical Care Physician/House Officer when the patient has arrived in the Emergency Department and deemed to be a Therapeutic Hypothermia candidate
6. Follow Steps 4-7 under Emergency Department to ICU Process Flow Section
B. Emergency Department (ED) to ICU Process Flow: The goal is for the patient to be transferred out of the ED within 30 minutes of being deemed appropriate for therapeutic hypothermia, unless extenuating circumstances exists (see Exhibit B for Ellis Health Center Process).
1. Patient presents to the Emergency Department post Cardiac Arrest.
2. Patient meets criteria for Therapeutic Hypothermia
3. The Emergency Department Nurse and/or designee will dial 911 and will alert the Operator to call a “Code Cool,” also stating patient name and location- Ellis Hospital ED. The “Code Cool” will notify E1, E2, ICU NM, Admitting, Supervisor and Respiratory Therapist.
4. The Emergency Room staff will ready the patient for ICU transfer (utilizing the Therapeutic Order Form-ED).
5. The ICU staff will prepare for patient’s arrival:
a. Obtains hypothermia supplies (device/equipment to induce hypothermia)
b. Notifies Critical Care Physician/House Officer
c. Notifies Maintenance: to cool room
d. Adjusts staffing as needed
6. The ED nurse calls report to the ICU nurse
7. Patient is transferred to the ICU
C. In-hospital Department to ICU Process Flow:
1. Code Blue team identifies a post-cardiac arrest patient that meets criteria for therapeutic hypothermia.
2. The floor nurse and/or their designee will dial 911 and will alert the Operator to call a “Code Cool,” also stating patient name and current location. The “Code Cool” will notify E1, E2, ICU NM, Admitting, Supervisor and Respiratory Therapist.
3. The ICU staff prepares for patient’s arrival:
a. Obtains hypothermia supplies (device/equipment to induce hypothermia)
b. Notifies Critical Care Physician/House Officer
c. Notifies Maintenance: to cool room
d. Adjusts staffing as needed
4. The floor nurse calls report to the ICU nurse
5. Patient is transferred to the ICU
D. Transferring Facility to ICU Process Flow (see Exhibit A):
1. Transferring facility identifies post-cardiac arrest patient that meets criteria for therapeutic hypothermia.
2. Transferring facility calls Ellis Hospital Emergency Department and requests a Code Cool be called. Transferring facility will state location (Nathan Littauer Hospital) and the patient’s estimated time of arrival.
3. Emergency Department RN or designee will dial 911 and alert the operator to call a Code Cool, location of the patient (Nathan Littauer Hospital), estimated time of arrival and patient name
4. If an ICU bed is available:
a. Upon receipt of the Code Cool page the ICU charge nurse or designee will contact the Critical Care Physician to inform them of an incoming therapeutic hypothermia patient.
b. ICU charge nurse or designee assigns an ICU bed and contacts transferring facility with the bed assignment. The ICU charge nurse or designee provides the transferring facility with the admitting physician’s contact information (facilitating MD to MD report).
c. The Ellis ICU RN and the admitting physician will obtain report from the transferring facility.
d. The ICU charge nurse or designee will contact admitting with the patient’s name, attending physician and bed assignment.
5. If an ICU bed is not available:
a. Ellis charge nurse or designee contacts admitting and informs them that no bed is available
b. Ellis admitting department contacts transferring facility and tells them to send patient to our Emergency Department.
c. Transferring facility provides MD to ED MD report as well as RN to ED RN report.
E. Induction of Hypothermia in the Intensive Care Unit: (initiate immediately as target timeframe is 6-8 hours to reach temperature goal of 33 degrees Celsius):
1. Ensure patient meets inclusion criteria, confirm full support status
2. Explain the purpose of hypothermia to the family and the need for pharmacologic paralysis (if ordered).
3. Offer pastoral care support to the family.
4. Gathers the necessary equipment, keeps door to room closed at all times
5. Obtain baseline labs as ordered (if not done in ED)
6. Turn off the room thermostat to cool the room
7. Uses only a Heat Moisture Exchanger (HME). Avoid using the ventilator heater/humidifier
8. Verify temperature monitoring method: Rectal, Espophageal, Pulmonary Artery Catheter, Foley device with temp sensor
9. Perform skin assessment
10. Perform a baseline neuro assessment and document findings on the appropriate flowsheet
11. Administer analgesics, sedatives and neuromuscular blocking agents as ordered
a. Ensure adequate pain control and sedation prior to initiating cooling, unless otherwise ordered
b. Initiate neuromuscular blockade prior to initiating cooling, unless otherwise ordered
c. Check and document Train of Four findings on the appropriate flowsheet utilizing the Peripheral Nerve Stimulator (according to Organizational Policy #7293 Neuromuscular Blockade using a Peripheral Nerve Stimulator).
12. Induces Hypothermia using chosen method on Therapeutic Hypothermia Order Form.
13. Monitors and Records temperature every 15 minutes throughout the induction phase.
14. Throughout the induction phase monitors for hypokalemia. Replace Potassium per physician orders.
15. Monitor for signs of shivering at least hourly and notify the physician immediately if signs of shivering are present.
16. Do not bathe the patient during the induction and maintenance phase.
F. Maintenance Phase:
1. Maintain a goal temperature of 33 degrees Celsius/91.4 degrees Fahrenheit for 24 hours.
2. If the patient awakens at any time discontinue hypothermia and notify the physician.
3. Continue to monitor for signs of shivering at least hourly and notify the physician immediately if signs of shivering are present.
4. Continue to obtain lab values as ordered
5. Maintain MAP 60-110 with IV fluids, vasopressors, or nitrates as ordered
6. Closely monitor for changes in rhythm and obtain a 12-lead EKG is needed (obtain order).
7. Assess neuro status every hour and PRN
8. Closely monitor urinary output and be alert for hypothermia induced diuresis.
9. Assess skin integrity every shift and PRN. Utilize the WOCN associates as needed.
G. Re-Warming Phase:
1. Initiate re-warming 24 hours after cooling/hypothermia was initiated (after induction was started)
2. Re-warm gradually utilizing the chosen method on the Therapeutic Hypothermia Order Form.
3. Turn on the room thermostat. Set to normal.
4. Turn on the ventilator heater/humidifier system
5. Continue to monitor for signs of shivering and notify the physician immediately if any signs of shivering are present.
6. Check and Record temperature every 15 minutes throughout the re-warming phase.
7. Monitor for hyperkalemia. Be sure to stop potassium administration 8 hours prior to the re-warming process.
8. Monitor for signs of hypoglycemia and hypotension.
9. Continue to draw labs as ordered.
10. Assess neuro status every hour and PRN during the re-warming process
11. Monitor for EKG changes.
12. Closely monitor urinary output.
13. Closely monitor skin integrity. Utilize the WOCN associates as needed.
14. Discontinue neuromuscular blockade first and then sedatives (30 minutes after neuromuscular blockade stopped), as ordered, once patient temperature reaches 36 degrees Celsius.
H. After the Re-Warming Phase:
1. Continue to monitor temperature every hour times four hours and then every shift. Be alert for temperatures over 38 degrees Celsius. Administer medications as ordered.
2. Continue to assess neurologic, cardiac, and renal status every shift and PRN. Document findings on the appropriate flowsheet.
EXHIBITS
Exhibit A: Nathan Littauer Hospital to Ellis Hospital Therapeutic Hypothermia Transfer Process
Exhibit B: Ellis Health Center Therapeutic Hypothermia Transfer Process
REFERENCES
1. American Heart Association: Circulation (2005). Induced Hypothermia
2. The New England Journal of Medicine. (2002). Mild Therapeutic Hypothermia to Improve the Neurologic Outcome after Cardiac Arrest.
ORIGINAL IMPLEMENTATION DATE: 10/05/09
REVIEW DATE: 10/09, 10/10, 05/11, 08/11
REVIEWED: 10/09, 05/10
REVISED: 10/09, 08/10
Exhibit A: Nathan Littauer Hospital to Ellis Hospital Therapeutic Hypothermia Transfer Process
Exhibit B: Ellis Health Center Therapeutic Hypothermia Transfer Process