Intensive Care Management from the Experts · Intensive Care Management from the Experts Dr. David Seder Maine Medical Center ... hospital cardiac arresthospital cardiac arrest should
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Intensive CareIntensive CareManagement from the ExpertsManagement from the Experts
Dr. David Seder Maine Medical CenterDr. David Seder Maine Medical CenterDr William Parham ANW Intensivist ProgramDr William Parham ANW Intensivist Program
Dr Lisa Kirkland ANW Intensivist ProgramDr Lisa Kirkland ANW Intensivist Program
Dr. Michael Mooney Program Director and ModeratorDr. Michael Mooney Program Director and Moderator
ObjectivesObjectivesReview the anticipated impact of therapeutic hypothermia onReview the anticipated impact of therapeutic hypothermia on cardiac output measurements
Describe the intravenous fluid infusion process for lowering body temperature
Discuss use of short-acting sedation and paralytics for therapeutic hypothermia
Summarize the induction, maintenance and rewarming phases of h i h h itherapeutic hypothermia
– 295,000 OHCA per year in US295,000 OHCA per year in US• 23% VF• 31% Bystander CPR
– Median survival all rhythms 7.9%, VF 21%– Best EMS systems: ie: Seattle 1998-2001 (resuscitated)
• 17.5% survival to hospital discharge • 34% VT/VF subgroup
IHCA adults: 19% (despite 95% witnessed or monitored)– IHCA adults: 19% (despite 95% witnessed or monitored)• Mortality among patients surviving to be hospitalized
• Multinational trialTH (33C) vs TN (36.5C) in CA survivors
• Niklas Neilsen PI• (INTCAR founder)
• Do we need to “prove” the efficacy of TH, again?
• What are the consequences of a• (INTCAR founder) consequences of a poorly designed or inconclusive trial result?
2005 AHA ACLS Guidelines• “Unconscious adult patients with ROSC after out-of-
hospital cardiac arrest should be cooled to 32°C tohospital cardiac arrest should be cooled to 32 C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours when the initial rhythm was VF (Class IIa).”
• “Similar therapy may be beneficial for patients with non-VF arrest out of hospital or for in-hospital arrest (Class IIb).”
Only 10% patients with OHCA will meet RCT criteria for TH
•The decision to
Risks
initiate TH is usually based on clinical judgement of risk and benefit, not on proof!
• Infections• Bleeding• Need for
sedation
Benefits• Strongly neuroprotective
• Decreased mortality• Better neurological
outcomeN Engl J Med 2002;346:549-56
TH after Cardiac Arrest
• Clinical criteria for therapeutic hypothermiaNo more than 8 hours have elapsed since the– No more than 8 hours have elapsed since the return of spontaneous circulation.
– Encephalopathy is present, typically defined as the patient being unable to follow verbal commands.
– There is no life-threatening infection or bleeding.– Aggressive care is warranted and desired by the
patient or the patient’s surrogate decision-maker• Terminal underlying disease• Impending cardiopulmonary collapse
• There are 3 phases of treatment:– InductionInduction
• Rapidly bring the temperature to 32-34C• Sedate with propofol or midazolam during TH• Paralyze to suppress heat production
– Maintenance• maintain the goal temperature at 33C• Standard 12-24 hours (optimal duration is unknown)• Suppress shiveringpp g
– De-cooling (rewarming)• Most dangerous period: hypotension, cerebral edema, seizures• Goal is to reach normal body temperature over 12-24h• Stop all sedation when normal body temperature is achieved
Induction: how to cool• Monitor core temperature
– Bladder esophagus or central venous/pulmonary– Bladder, esophagus, or central venous/pulmonary arterial
• Cold fluid– 30cc/kg LR or 0.9%NS over 30 minutes
• 2-2.5C temperature reduction– No adverse cardiovascular results
Rare to cause pulmonary edema– Rare to cause pulmonary edema• Ice packs and cooling mats
– Effective, but difficult to control rate of temperature change
• Commercial cooling devicesSer o mechanism aries temperat re of– Servo mechanism varies temperature of circulating water or air (prevents overcooling)
– External (surface cooling) systems• Hydrogel heat exchange pads• Cold water circulating through plastic “suit”• Cold water immersion – awaiting safety datag y
– Invasive (catheter based) systems• Heat exchange catheter in SVC or IVC• Plastic or metalic heat-exchange catheter
Cold IVF• Polderman 2005
– 110 patients, 2-3L over 50’Bernard 2003
- 22 patients 30cc/kg LR at 4°C 30 i 3 °C 33 8°C
p ,– 36.9°C to 34.6°C, MAP
increased by 15mmHg, no pulmonary edema
over 30 min: 35.5°C to 33.8°CImprovements in MAP, renal function, no pulmonary edema
Polderman. Crit Care Med 2005;33:2744Bernard. Resuscitation 2003;56:9
1. Central Venous Pressures1. Central Venous Pressures
•• Managing MAP > 60 and CVP >8 Managing MAP > 60 and CVP >8
•• CO /Index frequency CO /Index frequency –– Value during hypothermia ?Value during hypothermia ?
•• Cardiac outputs on done upon arrival to ICU; what Cardiac outputs on done upon arrival to ICU; what Cardiac outputs on done upon arrival to ICU; what Cardiac outputs on done upon arrival to ICU; what should a protocol suggest to followshould a protocol suggest to follow
•• Cooling Cardiac output vs normal temp Cardiac Cooling Cardiac output vs normal temp Cardiac Output?Output?
2. Sedation vs Paralytics 2. Sedation vs Paralytics •• Shorter acting Sedation and use of Shorter acting Sedation and use of Shorter acting Sedation and use of Shorter acting Sedation and use of
Paralytics Paralytics
•• What about Versed, Precedex, Propofol ?What about Versed, Precedex, Propofol ?
•• Train of 4 monitoring, Train of 4 monitoring, D/C paralytic when temp back at 36. C vs 37.0 CD/C paralytic when temp back at 36. C vs 37.0 C
•• Consider bolus dosing vs continuous dripConsider bolus dosing vs continuous drip
5. Non Phamaceutical 5. Non Phamaceutical Interventions for shiveringInterventions for shivering
•• Shivering how do we control it?Shivering how do we control it?•• Shivering, how do we control it?Shivering, how do we control it?
•• What are some Non pharmaceutical What are some Non pharmaceutical interventions we can apply? interventions we can apply?
D h t d t i it h i t?D h t d t i it h i t?•• Do heated vent circuits have impact?Do heated vent circuits have impact?
6. Management of fever post 6. Management of fever post coolingcooling
•• How should we treat the “rebound How should we treat the “rebound •• How should we treat the rebound How should we treat the rebound fever” after cooling is stopped?fever” after cooling is stopped?