Morning Report: 5/17/2013

Here’s Dr. Jegede with today’s Morning Report!

Therapeutic Hypothermia

• It’s benefits are compared to early defibrillation for improving survival in patients post cardiac arrest
• NNT to improve survival is 7. NNT to improve neurologic outcome is 5
• Should be started as early as possible. According to 1 study, there is a 20% increase in mortality for every hour of delay in the initiation of therapeutic hypothermia.

Indications

• Class I recommendation for patients who achieved Return of Spontaneous Circulation (ROSC) after a V tach/fib arrest.
• Protocol extended to patients who achieved ROSC with rhythms other than v tach/v fib (Class IIb recommendation)
• Comatose after ROSC, and by comatose meaning failure to respond to meaningful verbal commands

Contraindications

• Risk of starting hypothermia protocol may be greater in patients who went into cardiac arrest due to other causes such as: severe sepsis, exsanguinations, intracranial hemorrhage, or pts with hypotension not responsive to vasopressors

Methods of Inducing Hypothermia

• Initiation: The easiest way is to use cooled IV fluids during or immediately after resuscitation to achieve a temp of 32 to 34 deg Celsius.  You may also use ice packs and cooling blankets to achieve hypothermia.
  • Placing a central line and using a cooling system. This allows for closer titration and maintenance of core temperature in the 32°C-34°C range can be accomplished using endovascular catheters
  • Maintenance: can be accomplished using external cooling techniques such as ice packs on the groin, neck and axilla.
  • Pts should remain in the hypothermic state for 12 to 24hours

Complications/Consequences

• Shivering: most common complication.  Sedation and analgesia should be provided to reduce shivering. Benzodiazepines are typically used for sedation and opiates for analgesia.
  • Magnesium sulfate can raise the shivering threshold. 4gm of Mag sulfate is recommended
  • If shivering persists, neuromuscular blockade with paralytics is recommended

• Hemodynamics
  • Bradycardia and prolongation of QT interval: typically well tolerated;  treat only if it causes hemodynamic instability
  • Hypotension: common;  Goal MAP: 80-100mm Hg to achieve adequate cerebral perfusion. Vasopressors may be started to achieve this goal.
  • Hyperglycemia: due to decrease insulin secretion  and increase insulin resistance.  Do not treat unless blood glucose >200mg/dl
  • Hypokalemia: hypothermia decrease  k+ level by intracellular shift of K+.  replete K+ with goal of 3.5 or above.

Rewarming:

• Should be slow with a target rate of 0.25 deg Celsius every hour until the patient achieves normothermia
• Will take 12 to 16hrs to achieve normothermia.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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