G-1.4 Hypothermia After Cardiac Arrest

THE UNIVERSITY OF ILLINOIS AT CHICAGO NO.: G-1.4
University of Illinois Medical Center DATE: November 2010
Chicago, Illinois PAGE: 1 of 7

UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO
CLINICAL CARE GUIDELINE

HYPOTHERMIA AFTER CARDIAC CARE ARREST
IN THE ADULT PATIENT

November 2010

Key Content Expert: Dr. Prendergast, Chair, Emergency Cardiac Care Committee

These systematically developed statements have been created to assist the practitioner in the formulation of
health care decisions in specific clinical circumstances. They are not to be construed as an inflexible set of
correct procedures or protocols.
In each clinical circumstance the exercise of individual judgment is essential.
Guidelines are based upon statistical averages and opinions of practicing clinicians. Variation from these
guidelines does not constitute improper care or improper professional judgment. Evaluation of these
variations requires detailed analysis of the facts and circumstances surrounding the individual patient’s
care.

THE UNIVERSITY OF ILLINOIS AT CHICAGO NO.: G-1.4
University of Illinois Medical Center DATE: November 2010
Chicago, Illinois PAGE: 2 of 7

UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO
CLINICAL CARE GUIDELINE

NO.: G-1.4
DATE: November 2010

SUBJECT: Hypothermia after Cardiac Care Arrest

OBJECTIVE
This clinical care guideline was developed to outline the protocols used in employing therapeutic
hypothermia post resuscitation.

DEFINITIONS

Therapeutic Hypothermia— Use of mild hypothermia techniques and interventions designed
to suppress many of the chemical reactions associated with reperfusion injury to order to
prevent or reduce cerebral injury in cardiac arrest survivors.

Post Resuscitation Care— Management of a cardiac arrest patient with return of
electrocardiographic complexes targeting an endpoint of a neurologically intact patient with a
spontaneous stable cardiac rhythm and an adequate urine output.

POSITION STATEMENT

1. Post resuscitation care is primarily supportive with low numbers of patient’s surviving to
discharge (5-30%)

2. Major complications of sudden cardiac arrest are severe neurologic impairment and death
due to ischemic brain injury.

3. Conventional cooling methods to induce mild therapeutic hypothermia have demonstrated
improved survival and neurologic outcomes after cardiac arrest

4. Studies support the use of conventional cooling to induce mild hypothermia in cardiac arrest
survivors within the 1st hours of restoration of spontaneous circulation

PROCEDURE

I. Patient Selection:
A. Age 18 or older
B. In-hospital or out-of hospital cardiac arrest with return of spontaneous circulation (initial
rhythm VF or pulse-less VT; Can consider PEA if return to normal rhythm)
C. Persistent coma post-arrest (no eye opening to pain, not following commands, no
speech, no purposeful movements to noxious stimuli)
D. Able to maintain a blood pressure to systolic of at least 90 mm Hg spontaneously or with
fluid and pressers
E. Intubation with mechanical ventilation

THE UNIVERSITY OF ILLINOIS AT CHICAGO NO.: G-1.4
University of Illinois Medical Center DATE: November 2010
Chicago, Illinois PAGE: 3 of 7

UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO
CLINICAL CARE GUIDELINE

II. Exclusion Criteria:
A. Age less than 18 years old
B. Temperature < 30° C post-arrest
C. Greater than 6 hours post arrest

III. Relative Exclusion Criteria: Patients in whom hypothermia may come with increased risk
include those with:
A. Known, pre-existing coagulopathy or bleeding diathesis; uncontrolled bleeding-
hypothermia may impair the clotting system.
B. Systemic infection/sepsis- hypothermia may increase the risk of infection and bleeding
C. DNR
D. Terminal Illness

IV. Monitoring:
A. Emergency Department
1. Vitals per ED routine
2. Temperature probe: rectal probe, bladder probe
3. Continuous cardiopulmonary monitoring
4. Monitor neurological status per ED routine
5. Notify physician of myoclonus, shivering, dysrhythmias, or sudden deterioration in
vitals signs

B. Intensive Care Units
1. Vitals per ICU protocol
2. Arterial line placement
3. CVP monitoring via central line
4. Temperature probe: bladder, swan or rectal probe
5. Continuous cardiopulmonary monitoring
6. Monitor neurological status per ICU routine
7. Notify physician of myoclonus, shivering, dysrhythmias, or sudden deterioration in
vitals signs

V. Targets:
A. Begin cooling within 1st hours of restoration of spontaneous circulation
B. Systolic BP: > 90 mm Hg
C. MAP: > 80 mm Hg
D. CVP: > 4-6 mm Hg or PCWP > 8 mm Hg (replete with NS prn to goal)
E. Temperature: 32-34° C
F. Time to reach temperature goal: 6-8 hours
G. Insulin infusion to keep BG < 180
H. Replete K+ up to 3.4
I. Check skin q2hours to monitor for burns from cooling blankets.

VI. Induction/Cooling:

THE UNIVERSITY OF ILLINOIS AT CHICAGO NO.: G-1.4
University of Illinois Medical Center DATE: November 2010
Chicago, Illinois PAGE: 4 of 7

UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO
CLINICAL CARE GUIDELINE

A. Rapid initiation of cooling to goal temperature (within 6-8 hours of initiation)
B. Patient may undergo other interventions, i.e. cardiac catheterization, thrombolytics,

anticoagulation, imaging procedures, if so required.

VII. External cooling with cooling blankets and ice

A. Eligibility confirmed, inclusion/exclusion criteria documented, and materials gathered
B. Place Ice packs to armpits, neck, torso, groin and limbs. Avoid packing ice on top of

chest; that may impair chest wall motion.
C. Apply two cooling blankets (above and below patient) surrounded by sheets.
D. Cold saline infusion can be performed via a peripheral line or femoral venous catheter to

assist in achieving goal temperature. The infusion is 30 cc/kg of 4° C normal saline over
30 minutes. This is NOT to be used via a jugular or subclavian line, as the safety via this
method is not yet known.
E. Monitor vitals, with particular attention to arrhythmia detection
F. Once temperature reaches 34° C, remove ice packs and if needed one cooling blanket.
Cooling blankets may be used to maintain temperature.
G. Maintain temperature 32-34° C for a total of 12-24 hours from time of initiation.

VIII. External cooling with Cooling Pads

A. Eligibility confirmed, inclusion/exclusion criteria documented, and materials gathered
B. Take patient’s temperature and place cooling pad on patient (per manufacturer’s

suggestion)
C. After applying pads, set target goal.
D. Monitor vitals, with particular attention to arrhythmia detection
E. Maintain temperature 32-34° C for a total of 12-24 hours from time of initiation.

IX. Sedation:

A. Propofol or Midazolam infusion titrate to deep sedation

1. Midazolam (Versed) infusion 0.125 mg/kg/hr and titrate to sedation

2. Propofol(Diprivan) infusion 1 mg/kg/hr and titrate to sedation while patient is

paralyzed

3. Document Richmond Agitation Sedation Score (RASS) and TOF monitoring hourly,

as applicable

4. Titrate sedation as needed to RASS-4 to prevent shivering (see below)

RASS: Richmond Agitation Sedation Score

+4 Combative Combative, violent, immediate danger to staff

+3 Very Agitated Pulls or removes tubes(s) or catheter(s);

aggressive

+2 Agitated Frequent nonpurposeful movements, fights

ventilator

+1 Restless Anxious , apprehensive but movements are not

aggressive or vigorous

0 Alert and calm

-1 Drowsy Not fully alert, but has sustained awakening to

voice (eye opening & contact>10 seconds)

-2 Light sedation Briefly awakens to voice( eye opening & contact

<10 seconds)

THE UNIVERSITY OF ILLINOIS AT CHICAGO NO.: G-1.4
University of Illinois Medical Center DATE: November 2010
Chicago, Illinois PAGE: 5 of 7

UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO
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-3 Moderate sedation Movement or eye opening to voice(but no eye

contact)

-4 Deep sedation No response to voice, but movement or eye

opening to physical stimulation

-5 Unarousable No response to voice or physical stimulation

X. Comfort:
A. Morphine or Fentanyl infusion titrate to comfort
1. Fentanyl 1-4mg/kg/hr infusion
2. Morphine 1-2mg/hr infusion

XI. Paralysis:

A. Once sedation has been achieved, administer paralytic. - Shivering, the body’s attempt
at maintaining homeostasis is a concern when trying to achieve a hypothermic state.
When using conventional cooling methods, it is necessary to sedate and paralyze the
patient once the procedure has begun. When using certain external cooling pads, it may
be necessary to sedate and paralyze the patient once the procedure has begun.

B. Initiate train of four(TOF) monitoring : monitor depth of paralysis- goal 1-2/4
C. Vecuronium 0.1 mg/kg bolus then 1mcg/kg/minute

1. Head of bed to 30°
2. Lacrilube to eyes q8hr
3. Discontinue once patient warmed to 36° C

XII. Fever Control:
A. Acetaminophen 500mg pr or NGT q6hr

XIII. XIII.GI prophylaxis:

A. Famotidine 20mg IV q12 hr
B. Lansoprazole 30mg qday per NGT

XIV. DVT prophylaxis:
A. Heparin 5000 units SQ q12hr
B. Lovenox 40mg SQ qday

XV. Shivering:
A. Demerol 25mg IV q 4hours prn

XVI. Labs:
A. Post-arrest: CBC, BMP, Coags, Cardiac enzymes, ABG
B. Q8 hours (for next 24 hours): CBC, BMP, Coags, ABG
C. Blood cultures to be drawn at 12 hours post initiation of cooling

IIIX. Re-warming:
A. Begin re-warming at 12-24 hours post-initiation.
B. Goal 0.5 – 1° C every hour (expect ~8 hours)

THE UNIVERSITY OF ILLINOIS AT CHICAGO NO.: G-1.4
University of Illinois Medical Center DATE: November 2010
Chicago, Illinois PAGE: 6 of 7

UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO
CLINICAL CARE GUIDELINE

C. Aim for slow re-warming (if rebound hyperthermia, treat with acetaminophen and cooling
blanket)

D. Passive re-warming (do not use warm air blanket unless temperature has not recovered
to 36° C after 12 hours of re-warming

E. Once temperature has reached 36°C, stop neuromuscular blocking agents. Once TOF
returns to 4/4, titrate sedation/analgesics to patient comfort.

F. Monitor for hypotension and hyperkalemia during re-warming phase

IIIX. Indications to Halt Hypothermia Protocol Early:
A. Significant dysrhythmias
B. Hemodynamic instability
C. Active bleeding
D. Sepsis
E. Pneumonia

References

Arrich J, Holzer M, Herkner H, et al. Hypothermia for neuroprotection in adults after
cardiopulmonary resuscitation. Cochrane Database of Systemic Reviews 2009, Issue 4. Art
No.:CD004128. DOI:10.1002/14651858.CD004128.pub2.

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation. 2005; 112[ Suppl I]: IV-84-IV-88.

Polderman K, Rijnsburger E, Peerdeman S, Induction of hypothermia in Patients with various
types of neurologic injury with use of large volumes of ice-cold intravenous fluid. Crit Care Med
2005; 33:2744-2751.

Bernard S, Buist M, Monteiro O. Induced Hypothermia using large volume, ice-cold intravenous
fluid in comatoses survivors of out-of-hospital cardiac arrest: a preliminary report. Resuscitation
2003; 56:9-13.

Nolan, J.P., et al., Therapeutic hypothermia after cardiac arrest: an advisory statement by the
advanced life support task force of the International Liaison Committee on Resuscitation.
Circulation, 2003. 108(1): p. 118-21.

Bernard, S.A., et al., Treatment of comatose survivors of out-of-hospital cardiac arrest with
induced hypothermia. N Engl J Med, 2002. 346(8): p. 557-63.

HACA, Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N
Engl J Med, 2002. 346(8): p. 549-56.

THE UNIVERSITY OF ILLINOIS AT CHICAGO NO.: G-1.4
University of Illinois Medical Center DATE: November 2010
Chicago, Illinois PAGE: 7 of 7

UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO
CLINICAL CARE GUIDELINE