Slides ROSC Lecture 3 Part 3

5/19/2018 Slides ROSC Lecture 3 Part 3

1/12

Arrest ROSC

2. When to s tart

coo l ing?

3. How deep

to cool?

1. How to cool?

4. How long to

keep cool?

temperatu

re

time

Practical issues of coolingPractical issues in therapeutic hypothermia

Time


2/12

University of ChicagoHospitals (UCH)initial experience (2003-4):

cooling blanketand/or ice packing

Advantages: cheap, non-invasive, off the shelf

Disadvantages: slow cooling, can be messy,lack of thermostatic control

How to cool?Our initial experiences with hypothermia


3/12

Merchant RM et al, 2006

Retrospective chart review of cooling cases

From three hospitals (2 in U.S., 1 in U.K.)

Found 20/32 cases (63%) were overcooled

Trends towards better outcome in non-overcooled pts

Suggests need for thermostatic feedback control

Difficulties with ice bag coolingOvercooling using ice for hypothermia


4/12

29

30

31

32

33

34

35

36

37

38

39

40

0 4 8 12 16 20 24 28 32

Time (hours)

Temperature(Ce

lsius)

Example A

Merchant RM et al, 2006

Surface cooling in the real worldAn example of a patient cooled with ice


5/12

Cooling was fast

65% cooled to target

within 60 minutes

77% failed to stay

cool during course

But maintenance was hard

Is cold saline enough?What about cold intravenous fluids?

Cold infusions alone are effective for induction of therapeuticHypothermia but do not keep patients cool after cardiac arrest

Kliegel et al, 2007


6/12

Study at one hospital in Switzerland

Survivors of out-of-hospital arrest

Cooling initially via ice bags, then cooling mattress

Target temperature 33oC, maintained for 24 hrs

Oddo M et al, 2006

Real world usage: SwitzerlandAn example from the real world of cooling patients

From evidence to clinical practice: Effective implementation of

therapeutic hypothermia to improve patient outcome aftercardiac arrest

Oddo et al, Critical Care Medicine 2006


7/12

CPC5 CPC3 CPC2 CPC156% 19% 12% 14%

CPC 5 .CPC3 CPC2 CPC140% 5% 14% 42%

Outcome at discharge for out-of-hospital VF arrest

baseline

cooling

Real world usage: SwitzerlandA real world example: cerebral performance category (CPC) outcomes


8/12

Real world usage: Switzerland

CPC5 CPC389% 11%

CPC5 CPC183% 17%

baseline

cooling

Outcome at discharge for out-of-hospital asystole arrest

A real world example: cerebral performance category (CPC) outcomes


9/12

Post-arrest care is a critical care bundle:

Therapeutic hypothermia

Careful blood pressure management

Treatment for coronary blockages

Brain and outcomes assessment

Post-arrest care is more than just cooling


10/12www.med.upenn.edu/resuscitation/Hypothermia.htm

Hypothermia resource websiteA public resource for more hypothermia information


11/12

Hypothermia Training Institute at Penn

Phi ladelphia next cou rse March , 2013

Intensive two day CME course in hypothermiamethods, protocols, and applications

Designed for critical care, cardiology or emergency medicine

physicians and nurse managersi.e., local champions

Offers hypothermia certification

Workshop designsmall course sizeheld quarterly

Training program for health care providers


12/12

Upcoming Coursera lectures in this program

Lecture 2: Rethinking CPR: quality of care andnew ideas about training

Lecture 3: Therapeutic hypothermia and post-resuscitation care

Lecture 4: Frontiers in resuscitation: reperfusionmedicine and cardiac bypass

Lecture 5: Survivorship and end-of-life issuesafter cardiac arrest

Documents

Slides ROSC Lecture 3 Part 3