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The Hypothermia After Cardiac Arrest Study Group Cooled

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Title: The Hypothermia After Cardiac Arrest Study Group Cooled


1
CHILL OUT/ SAVE A BRAIN FOR LATER USE!
Kenny Lawrence, RN Northeastern State
University EBP Symposium April 23,
2010 kenrn_at_sbcglobal.net
2
CHILL OUT/ SAVE A BRAIN FOR LATER USE!
  • Each year there are an estimated 295,000
    emergency medical services-treated out-of
    hospital cardiac arrests in the United States.
  • Source
  • American Heart Association. (2010). Heart Disease
    and Stroke Statistics. Retrieved from
    http//americanheart.org/downloadable/heart/12656
    65152970DS324120HeartStrokeUpdate_2010.pdf

3
NEUROLOGICAL STATISTICS
  • Ten to thirty percent of patients who survive an
    out-of-hospital cardiac arrest will have
    permanent brain damage.
  • Source
  • McKean, S. (2009). Induced Moderate Hypothermia
    After Cardiac Arrest. AACN Advanced Critical
    Care, 20, 343.

4
In-Hospital Cardiac Arrests
  • The rates of survival to discharge after
    in-hospital cardiac arrest are 27 among children
    and 18 among adults.
  • Source
  • American Heart Association. (2009).
    Out-of-Hospital Cardiac Arrest Statistical Fact
    Sheet.
  • Retrieved from http//www.americanheart.org/downl
    oadable/heart/1236978541670OUT_OF_HOSP.pdf

5
Current Research
  • Therapeutic hypothermia has been shown to provide
    neuro-protective properties in the post-cardiac
    arrest victim.

6
Learning Objectives
  • Discuss pertinent research findings that lead to
    the AHA 2005 guidelines for post resuscitation
    induced hypothermia.
  • Analyze the neuro-protective benefits of
    therapeutic hypothermia in the post cardiac
    arrest patient.

7
HYPOTHERMIA A HISTORICAL PERSPECTIVE
  • Hippocrates advocated packing wounded patients in
    snow and ice to reduce hemorrhage. We dont have
    records of his statistics to know if it worked.

8
HYPOTHERMIA A HISTORICAL PERSPECTIVE
  • In the 1950s, hypothermia was utilized for
    intracranial aneurysm clipping and for cardiac
    surgery during circulatory arrest. Since this is
    no longer used, it makes you wonder how effective
    it was.

9
HYPOTHERMIA A HISTORICAL PERSPECTIVE
  • In the 1960s, clinical trials with hypothermia
    (30 C or lower) were discontinued because of
    side effects, uncertain benefits and management
    problems (BRRR.is that frostbite?).

10
HYPOTHERMIA A HISTORICAL PERSPECTIVE
  • In the 1980s, animal studies were conducted that
    showed benefits using a milder more controlled
    hypothermia (32-34C) with fewer side effects.

11
Research on Therapeutic Hypothermia
  • In 2002 the Bernard and Hypothermia After Cardiac
    Arrest (HACA) studies were done.

12
HACA
  • The Hypothermia After Cardiac Arrest
  • Study Group
  • Cooled patients to a target of 33C for 24 hours
    after cardiac arrest and ROSC using cooling
    blankets. Ice packs were required in 70 of the
    patients.
  • Population adult comatose survivors of VF or
    pulseless VT arrest in the field.

13
HACA
  • 137 patients were cooled (hypothermia group) 138
    patients were not (normothermia group).
  • Neurological status six months after cardiac
    arrest was the primary measurement in this study.

14
HACA
  • 55 of the patients in the hypothermia group had
    favorable neurological outcomes six months after
    cardiac arrest.
  • 39 of the patients in the normothermia group had
    favorable neurological outcomes six months after
    cardiac arrest.
  • Source
  • Ramsay, P. Maxwell, R. (2009). Advancements in
    Cardiopulmonary Resuscitation Increasing
    Circulation and Improving Survival. American
    Surgeon, 75, 359-362.

15
Bernard Study
  • Cooled patients with the removal of clothing and
    the application of ice packs to the head and
    torso to a target of 33C for 12 hours.
  • Population adult survivors of out-of-hospital
    VF arrest. Patients were randomly assigned to
    normothermia or hypothermia treatment groups.

16
Bernard Study
  • 43 patients were cooled (hypothermia group) 34
    patients were not (normothermia group).
  • 49 of the hypothermia group survived discharge
    to home or a rehabilitation facility with
    favorable neurological outcomes.

17
Bernard Study
  • 26 of the normothermia group survived discharge
    to home or a rehabilitation facility with
    favorable neurological outcomes.
  • Source
  • Collins, T., Samworth, P. (2008). Therapeutic
    hypothermia following cardiac arrest a
  • review of the evidence. Nursing In Critical
    Care, 13, 144-151.

18
2002 ILCOR
  • On the basis of the published evidence to date,
    the Advanced Life Support (ALS) Task Force of the
    International Liaison Committee on Resuscitation
    (ILCOR) made the following recommendations in
    October 2002

19
2002 ILCOR
  • Unconscious adult patients with
  • spontaneous circulation after out-of-hospital
  • cardiac arrest should be cooled to 32C to
  • 34C for 12 to 24 hours when the initial
  • rhythm was ventricular fibrillation (VF).
  • Such cooling may also be beneficial for other
  • rhythms or in-hospital cardiac arrest.

20
2005 AHA GUIDELINES FOR POST RESUSCITATION
INDUCED HYPOTHERMIA
  • Class I Benefit gtgt Risk (Strongest)
  • Class IIa Benefit gt Risk
  • Class IIb Benefit gt Risk
  • Class III Benefit lt Risk (Harm)

21
2005 AHA GUIDELINES FOR POST RESUSCITATION
INDUCED HYPOTHERMIA
  • Comatose out-of-hospital adult patient with ROSC
    after VF
  • Class IIa recommendation
  • In-hospital arrest, other rhythms Non VF, PEA,
    Asystole e.g.
  • Class IIb recommendation

22
Post Cardiac Arrest Syndrome
  • Post cardiac arrest syndrome is a unique and
    complex
  • combination of pathophysiological processes,
    which
  • include post cardiac arrest brain injury,
    post
  • cardiac arrest myocardial dysfunction and
    systemic
  • ischemia/reperfusion response. This state is
    often
  • complicated by a fourth component the unresolved
  • pathological process that caused the cardiac
    arrest.
  • Source
  • ILCOR Consensus Statement. (2008). PostCardiac
    Arrest Syndrome. Circulation, 118, 2452-2483.
    doi 10.1161/CIRCULATIONAHA.108.190652

23
Reperfusion Injury
  • Reperfusion (return of adequate blood flow and
    oxygen) initiates chemical processes that lead to
    inflammation and continued injury in the brain.
  • Reperfusion injury is thought to include the
    release of free radicals, nitric oxide,
    catecholamines, cytokines, and calcium shifts,
    which all lead to mitochondrial damage and cell
    death.
  • This process may last as long as 24 to 48 hours

24
Post Cardiac Arrest Brain Injury
  • The brain has a small amount of oxygen stores.
    When cerebral perfusion and oxygen delivery stop
    during cardiac arrest, the oxygen stores are
    depleted within 20 seconds.
  • After oxygen is depleted, the brain turns to
    anaerobic metabolism to sustain function.

25
Post Cardiac Arrest Brain Injury
  • Glucose and adenosine triphosphate (ATP) levels
    are depleted after 5 minutes if return of blood
    flow is not achieved. This causes ion pumps that
    use ATP to fail, allowing for electrolyte
    imbalances including potassium, sodium, and
    calcium, resulting in cellular edema and cell
    death.

26
MECHANISMS OF NEUROPROTECTION
  • CEREBRAL METABOLISM IS DECREASED
  • The cerebral metabolic rate is decreased by 6
    to 7 for every 1C decrease in body temperature.
    Decreasing the cerebral metabolic rate decreases
    cerebral oxygen consumption.
  • Source
  • Koran, Z. (2009). Therapeutic hypothermia in
    the postresuscitation patient the development
    and implementation of an evidence-based protocol
    for the emergency department. Journal Of Trauma
    Nursing The Official Journal Of The Society Of
    Trauma Nurses, 16, 48-57.

27
MECHANISMS OF NEUROPROTECTION
  • INFLAMMATORY AND IMMUNOLOGICAL RESPONSES
  • Hypothermia is also thought to decrease many of
    the chemical reactions that occur during
    reperfusion, such as free radical production
  • Temperatures less than 35C lead to decreased
    neutrophil and macrophage functions. This reduces
    the inflammatory response that is initiated after
    ischemia.

28
Why Perform Therapeutic Hypothermia
  • Mild hypothermia is the only therapy applied in
    the post cardiac arrest setting that has been
    shown to increase survival rates and neurological
    outcomes.
  • Source
  • ILCOR Consensus Statement. (2008). PostCardiac
    Arrest Syndrome. Circulation, 118, 2452-2483.
    doi 10.1161/CIRCULATIONAHA.108.190652
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