Pennsylvania Hospital Nursing Subject: Clinical Guideline: Hypothermia Therapy for Post-Cardiac Arrest Adult Patients Keywords Hypothermia Therapy (HT) Cooling Therapy Return of Spontaneous Circulation (ROSC) Train of Four (TOF) Peripheral Nerve Stimulator Neuromuscular Blockade Agent (NMBA) Mean Arterial Pressure (MAP) Nursing Practice Manual Critical Care Page 1 of 7 INTRODUCTION: Sudden cardiac arrest is a major health concern with more than 400,000 deaths annually in the United States. There is a 5-30 % survival rate to hospital discharge for those patients successfully resuscitated post cardiac arrest. Ischemic brain injury as a result of the cardiac arrest leads to poor neurological outcomes and death. Hypothermia Therapy (HT), also referred to as cooling therapy, has been shown to improve neurological outcomes for some post-cardiac arrest patients. PURPOSE: To outline the major care priorities in Hypothermia Therapy (HT) during the resuscitative period for the patient while in critical care. Induction, maintenance and rewarming take place only in the Adult Critical Care Units and only after inclusion criteria have been satisfied. SCOPE OF PRACTICE: This policy pertains to all RNs, NPs, PAs and physicians providing treatment or care to patients located in the Adult Critical Care Units (3S, 3WA and 3WB only). PATIENT SELECTION: EVALUATION, ELIGIBILITY AND EXCLUSION CRITERIA The Critical Care Medicine Attending physician determines the eligibility for HT based on the following inclusion criteria: o Post cardiac arrest with return of spontaneous circulation (ROSC) less than 60 minutes. o Onset of cardiac arrest less than 12 hours prior to induction of cooling therapy o Glasgow Coma Scale (GCS) Motor Score is less than 6 i.e. the patient does not follow commands. o Pre- cardiac arrest cognitive status intact i.e. no neurological dysfunction e.g. dementia o Adult- age greater than 18 years. o If patient is pregnant, OB/GYN has been consulted. o MAP greater than 65 with or without vaosoactive medication support. Ineligibility is based on the following exclusion criteria: • Coagulopathy • DNR/DNI status • Relative contraindication is major intracranial, thoracic or abdominal surgery within the past 14 days. The Critical Care Medicine Attending physician will: o Review patient history, presentation, assessment, evaluation and diagnostic results. o Discuss risks/benefits of induced hypothermia therapy with family, including risk for infection, increased bleeding, and cardiac arrhythmias. o Complete the induced hypothermia inclusion /exclusion criteria in SCM and enter the orders to begin HT PJD C:\Documents and Settings\doquin\Desktop\policy.docPage Pennsylvania Hospital Nursing Subject: Clinical Guideline: Hypothermia Therapy for Post-Cardiac Arrest Adult Patients Nursing Practice Manual Critical Care Page 2 of 7 EQUIPMENT 1. Gaymar III Cooling System (hypothermia unit) with 2 sets of hoses (maintained and stored in the 3W Clean Utility Room). Important: These special hoses (with Quick-Click Connectors) DO NOT LEAVE the 3rd Floor. Disinfect with germicidal wipes after use and return to 3W Clean Utility Room. 2. Disposable Rectal Temperature Probe (Stored in 3 Widener Clean Utility Room above cooling units) 3. Gaymar RaprRound Body Wraps (Call SPD to reorder as needed); SPD storeroom locations are as follows: • Leg Wraps (2) and SPD Location 15 – F0 – A • Large Vest (1) or SPD Location 15 – F0 – B • Small/Medium Vest (1) SPD Location 15 – F0 – C 4. Arterial line (A-line) kit 5. Central Venous Catheter (CVC) 6. Flush system set up for A-line and CVC. Important: No Heparin. 7. (2) 1 liter bags of chilled 0.9% Normal Saline (4˚C) stored in Med Room refrigerators; replace at once. 8. (1) 500 mL bottle of D5W and (2) 250 mL bags of D5W chilled in Med Room refrigerator; replace at once. 9. Foley catheter 10. 2 pressure bags (one each for A-line and Iced Saline infusion) 11. Order chilled D5W for all drips from the Pharmacy Department, e.g. sedation, vasopressors, NMBA, etc. Pharmacy will routinely store a supply of chilled D5W solutions for this purpose. 12. 2 peripheral 18 gauge IV sites 13. Peripheral Nerve Stimulator (PNS) for Train of Four (TOF) testing; the portable PNS is kept on the unit in the Med Cart. Return the PNS after cleaning with a germicidal wipe to the Med Cart. 14. BAIR Hugger warming unit 15. BAIR Hugger 241 Blood/Fluid Warming Set (stored on wall behind the Gaymar Cooling Units on 3W) PROCEDURE A. COOLING PROTOCOL (Induction and Maintenance): Goal for Induction: Target temperature range is 32 - 34°C within 4 hours of protocol activation. If unable to arrive at target T °C within 6 hours, notify CC attending physician or resident physician. Once at target T °C, notify resident to discontinue Induction phase orders in SCM. Resident will then enter Maintenance phase orders in SCM. Goal for Maintenance: Maintain target temperature range of 32 - 34°C for 24 hours from the time the target temperature range is first met. 1. Answer any questions the family or patient representative may have before beginning therapy. 2. Verify line placement prior to initiation of the cooling phase since lines are difficult to place once hypothermia is initiated. Line/tube placement includes: o 2 large gauge peripheral IVs o Arterial line o Central Venous Catheter o Foley catheter and o NG Tube or OG Tube. Important: Do not use Heparin in the flush bags since heparin’s effect will be enhanced by HT i.e. increased risk for bleeding 3. Verify the patient has been intubated and sedated per the ICU Sedation Protocol [Refer to Richmond Agitation – Sedation Scale (RASS), Sedation Protocol and Sedation and Analgesia Policy; see Resources]. The goal for sedation for this patient is a RASS score of – 4. 4. Obtain STAT labs (CBC, PT/PTT, Chemistry Panel, Arterial Blood Gas, CK Total and Troponin Ultra, Lactate level and LFTs; obtain HCG for all female patients of child bearing age) 5. Room thermostat turned to OFF. Pennsylvania Hospital Nursing Subject: Clinical Guideline: Hypothermia Therapy for Post-Cardiac Arrest Adult Patients 6. 7. 8. 9. Nursing Practice Manual Critical Care Page 3 of 7 Administer antibiotic as ordered and document time of administration. Observe for myoclonic jerks prior to HT induction; notify physician. Administer loading dose of antiseizure medication as ordered and document time of administration. Infuse 2 liters iced saline (0.9% Sodium Chloride) or 40mL/kg at 4˚C through the peripheral IVs (to a maximum of 2 liters) and record total amount of iced saline on intake record. Obtain Gaymar III external cooling unit with two complete sets of hoses and one disposable rectal probe; this unit will be stored in the Clean Utility Room on 3 Widener. The cooling unit must have 2 sets of hoses with Quick-Click Connectors to operate with the vest and leg appliances. Also procure from 3 Widener’s Clean Utility Room: o One Gaymar Torso wrap (Medium or Large) o Two Leg cooling wraps 10. 11. 12. 13. 14. Note: If using this Gaymar III unit as a regular cooling blanket, you must disconnect the 2 sets of QuickClick hoses and connect a single set of regular hoses which are stored on the back of the cooling unit. Obtain a cooling blanket from SPD. Follow instructions for Setting up the Gaymar III (See Electronic Resources) to arrive at target hypothermia temperature. This appendix describes the step-by-step application of the cooling apparatus and adjustments nursing will make to arrive at target temperature. Use Rapid Cooling Automatic mode of operation for cooling therapy. Set Temperature to 34˚C. When patient is at 34˚C (beginning of Maintenance Phase), change mode to Gradual Cooling Automatic mode and adjust Temperature to 33˚C. Assess shivering hourly. Shivering Scale: Mild- facial tremors Moderate- extremity tremors Severe- full body tremors Train of Four (TOF) Testing: Conduct a baseline TOF test in anticipation of a need for neuromuscular blockade (NMB) during HT. Follow orders to initiate neuromuscular blockade if its use is being considered for management of moderate to severe shivering. . Optimize sedation before NMB is initiated. (Refer to Peripheral Nerve Stimulator and Train of Four policy; see Section G, Electronic Resources). Obtain a fresh battery before TOF testing is initiated. Electrode Placement: Distal electrode (black) is placed at crease of wrist along the ulna nerve’s path Proximal electrode (red) is placed about 4 inches above the wrist level along the same nerve path Goal for NMB: 1-2 twitches of 4 twitches with Peripheral Nerve Stimulator. 15. Have a BAIR Hugger and Blood/Fluid Warming set available for use in the event the target temperature is overshot and you need to increase body temperature. The Blood/Fluid Warming set used with the BAIR Hugger unit is stocked in unit Clean Utility rooms above the Gaymar III units. 16. Have the Respiratory Therapist place the ventilator humidifier OFF. 17. In the Maintenance phase when the patient’s temperature reading is in the target temperature range of 32 - 34°C, the Gaymar III unit will continue to operate in the Gradual Cooling Automatic mode of operation. Set a target temperature of 33˚C. The patient will be maintained in this target temperature range for 24 hours. Do not make any adjustments to the cooling unit while in the Gradual Cooling Automatic mode. Pennsylvania Hospital Nursing Subject: Clinical Guideline: Hypothermia Therapy for Post-Cardiac Arrest Adult Patients Nursing Practice Manual Critical Care Page 4 of 7 B. RE-WARMING PROTOCOL Goal: Slowly return core temperature to 36.5˚C over the course of 6-8 hours. The re-warming phase begins when the target temperature range (32 – 34 °C) has been maintained for a period or 24 hours. Once at target T °C for 24 hours duration, notify resident to discontinue Maintenance phase orders in SCM. Resident will then enter Re-warming phase orders in SCM. 1. Report CVP to physician prior to re-warming to address volume status and IV fluid adjustment 2. Report last Potassium level to physician; anticipate the removal of all Potassium from IV fluids prior to the initiation of the re-warming phase. 3. Document time the re-warming is initiated 4. Increase Gaymar III setting by 0.5°C every 1 to 2 hours using the Gradual Automatic mode of operation (See Appendix A). Patient’s hemodynamic response to re-warming will dictate the duration of the Re-warming phase. 5. DO NOT exceed 0.5-1˚C/hour increases in temperature during re-warming 6. Have NMBA discontinued by the physician when temperature reaches 36°C. Continue to monitor level of paralysis until TOF test is 4 of 4 twitches. At 36.5°C, adjust sedation to achieve a RASS score of (-2). NOTE: If shivering emerges after the NMB has been discontinued, consider the use of meperidine for control of mild to moderate shivering. 7. STOP active re-warming once the temperature of 36.5˚C is reached. Do not allow the patient to become HYPERthermic in the re-warming phase 8. Room thermostat should then be turned to ON 9. Have the Respiratory Therapist set the ventilator humidifier ON. . 10. Document time re-warming goal temperature is reached. 11. After re-warming is completed, consult physician for DVT prophylaxis orders. 12. Tylenol 650 mg suppository PR should be used to control fever for the first 24 hours after re-warming is completed. 13. When T reaches 36.5°C, notify the Resident that re-warming has been completed. Resident will then enter the Post Therapy phase orders in SCM. C. DOCUMENTATION: 1. 2. 3. 4. 5. Use VISICU electronic record or, during downtime procedure, the Critical Care flow sheet to record: BP, MAP, HR, Pulse Oximetry, cardiac rhythm and CVP as follows: • Every 15 minutes during initiation of cooling until target temperature is reached • Every hour during the maintenance phase • Every 15 minutes during re-warming phase until target temperature range of 36.5-37˚C is achieved. • Every hour x 12 additional hours after re-warming is completed and as condition warrants Hourly Neuro checks Record rectal Temperature in °C every 15 minutes until 32 - 34˚C is reached, then every 30 minutes, and again every 15 minutes during re-warming. Record Temperature in °C every hour for 12 hours after rewarming is completed and as condition warrants. Monitor Foley output hourly since patient may require frequent volume replacement as HT induces diuresis. Continuous cardiac monitoring. Please note: HT initially causes a sinus tachycardia, then bradycardia. The arrhythmia most commonly associated with HT is V-Fib. Other ECG changes may include prolonged Q-T interval and the occurrence of a J wave. Pennsylvania Hospital Nursing Subject: Clinical Guideline: Hypothermia Therapy for Post-Cardiac Arrest Adult Patients Nursing Practice Manual Critical Care Page 5 of 7 D. BLOOD PRESSURE MANAGEMENT Cooling Phase: Goal: MAP greater than 65 and less than 120. Follow orders for nitroglycerin IV infusion titrated to a MAP less than 120 or obtain physician order for a suitable alternative IV anti-hypertensive medication. Rationale: HT may cause severe vasoconstriction leading to HYPERtension. Re-warming Phase: Follow order for norepinephine or dopamine hydrochloride or obtain a physician order for a suitable alternative titrated to maintain MAP greater than 65. Rationale: Re-warming causes vasodilatation leading to HYPOtension and HYPOvolemia. Vasoactive medication support may be necessary during re-warming to correct severe vasodilation. E. LABS, ELECTROLYTES AND RADIOLOGY 1. Stat Labs: o Lactate level o LFTs o CBC with Diff and PLTs o PT/PTT o Chemistry Panel including Ca, Mg and Phosphorus o CPK Total and Troponin Ultra o Arterial Blood Gas (ABG) o HCG (for female patients of child-bearing age) 2. Ongoing Labs every 6 hours during the cooling and re-warming phases of therapy: o Arterial Blood Gas o Central venous oxygen saturation o CBC with Diff and PLTs o Chemistry panel including Ca, Mg and Phosphorus o CPK Total and Troponin Ultra o Lactate level 3. Potassium: Monitor serum potassium every 6 hours during Cooling Induction and Maintenance phases. Obtain a STAT Potassium level prior to re-warming and report result to resident physician. Monitor potassium every 4 hours during Re-warming phase. Rationale: When HT is initiated, HYPOkalemia is a result of intracellular potassium shift exacerbated by the cooling therapy. With re-warming, the potassium will move back into the serum, so more frequent monitoring of potassium levels is indicated. 4. Glucose: Monitor finger-stick glucose levels every hour. (Refer to the Insulin Protocol for glucose management; see Section G, Electronic Resources). Rationale: Cooling therapy leads to decreased insulin secretion and decreased sensitivity causing HYPERglycemia. HYPERglycemia, in turn, contributes to increased brain ischemia. Re-warming resolves resistance to insulin and puts the patient at risk for developing a rebound HYPOglycemia. Monitor glucose levels hourly for this reason. 6. CXR: Daily portable CXR 7. EKG: STAT EKG to be collected with induction of HT and then routinely every 8 hours times two. Pennsylvania Hospital Nursing Nursing Practice Manual Subject: Clinical Guideline: Hypothermia Therapy for Post-Cardiac Arrest Adult Patients Critical Care Page 6 of 7 F. Infection Prevention and General Nursing Care 1. Follow Isolation Precautions is so ordered. 2. Use meticulous aseptic technique with all invasive lines and procedures 3. Maintain compliance with vigorous hand washing by all care givers and visitors 4. Administer prophylactic antibiotics as ordered 5. Provide oral care every 4 hours and as needed. 6. Skin integrity checks every 1 hour; reposition patient every 2 hours to prevent skin breakdown. 7. Eye care every 2 hours: apply lubricant to eyes per medication order. G. Electronic RESOURCES Instructions for Setting up the Gaymar III Cooling System Hypothermia http://uphsxnet.uphs.upenn.edu/pahhome/criticalcare/pandp/protocols/hypothermia.pdf Peripheral Nerve Stimulator and Train of Four (Ch. 104 of AACN Manual, pp. 837-45.): http://app32.webinservice.com/content/Library/AACN_104.pdf Sedation Protocol (CC homepage): http://uphsxnet.uphs.upenn.edu/pahhome/criticalcare/pandp/protocols/Sed ationProtocolFlowsheet.pdf Sedation Analgesia Policy (Administrative Policy CA 10) http://uphsxnet.uphs.upenn.edu/pahhome/pahpolicies/CA10.pdf RASS Scale (CC homepage): http://uphsxnet.uphs.upenn.edu/pahhome/criticalcare/resources/RASS.pdf Insulin Drip Protocol (CC homepage): http://uphsxnet.uphs.upenn.edu/pahhome/criticalcare/insulinprotocol.pdf REFERENCES: American Heart Association. Part 7.5: Post Resuscitation Care. Circulation 2005;112(suppl I) IV84-IV88. Bader MK, Rovzar M, Baumgartener L, Winokur, R, Cline J and Schiffman G. Keeping Cool: A Case for Hypothermia After Cardiopulmonary Resuscitation. American Journal of Critical Care. 2007;16:636-640 . Bernard, S. Hypothermia for Cardiac Arrest. In: Mayer SA, Sessler, DI, eds. Therapeutic Hypothermia. New York, NY: Marcel Dekker: 2005:473-488. Bernard SA, Gray TW, Buist MD, et al. Treatment of Comatose Survivors of Out-ofHospital Cardiac Arrest with Induced Hypothermia. New England Journal of Medicine.2002;346(8): 557-563 Holden, M., Makic, MBF. Clinically Induced Hypothermia: Why Chill your Patient? AACN Advanced Care 2006:17(2), 125-132. Critical Pennsylvania Hospital Nursing Subject: Clinical Guideline: Hypothermia Therapy for Post-Cardiac Arrest Adult Patients Nursing Practice Manual Critical Care Page 7 of 7 SUPERCEEDS: NONE REVIEWS/APPROVALS: Nursing Policy and Procedure Committee (1/09), (2/11) CC Committee (01/09) and (02/11) and Resuscitation Committee, 01/09, (1/11) EFFECTIVE DATE: February 2011 SIGNATURE: _______________________ Mary Del Guidice, RN, MSN, BS, NE-C Chief Nursing Officer APPENDIX Temperature Conversion Scale °F 105° 104° 103° 102° 101° 100° 99° 98° 97° 96° 95° 94° 93° 92° 91° 90° 89° 88° 87° 86° °C 40.6° 40° 39.4° 38.9° 38.3° 37.8° 37.2° 36.7° 36.1 ° 35.6° 35° 34.4° 33.9° 33.3° 32.8° 32.2° 31.7° 31.1 ° 30.6° 30° Activating Conditional Orders Background: There is a new feature to the Hypothermia Protocol order set which will allow you to activate serial lab orders and EKG studies when they are due for collection. It’s called the Conditional Order. By activating these Conditional Orders, you’ll be able to print out labels and send the specimens off to the Lab or Respiratory Services for analysis as the protocol dictates. You are required to ACTIVATE STAT and serial Lab and EKG orders for HT patients. See steps for activating Conditional Orders (next page). TYPES of Labs and Studies in HT Protocol: A. Serial Labs: Frequency: Induction & Cooling and Maintenance phase - Every 6 hours Re-warming - Every 6 hours Post-Therapy Phase - Every 12 Hours Types: ABG (Arterial) /Lactic Acid POC ICU ABG (Venous) POC ICU CBC/Diff/Platelets ICU PT (Prothrombin Time) / INR ICU PTT (Activated Part Thromboplastin Time) Electrolyte Panel 7 ICU Magnesium Serum ICU Phosphorus, Serum ICU CK Total. ICU Troponin Ultra ICU B. Serial EKGs: Every 8 Hours x 2 after STAT order is collected during Induction & Cooling. Serial EKGs should not extend beyond Maintenance Phase. These POC labs are to be “Completed” in SCM by the RN once they are given over to Respiratory Services These labs will be “Pending Collection” or “Results Pending” until such time as the Central Lab enters the results and “Completes” the order in SCM. These serial EKGs are to be “Completed” in SCM by the RN once they collected. C. STAT Labs • All STAT Labs are collected in the usual manner and “auto complete” once the request for a label is generated. Most STAT Labs are collected in Phase I (Induction and Cooling) • Potassium STAT: (Potassium, Serum ICU): Send a STAT Potassium level at the end of Maintenance and before Re-warming begins. Treat this order as any STAT order and “activate” accordingly; this type of order “auto completes” itself. Steps for Activating Conditional Orders: 1. On the Order tab, select a conditional order (it has a icon next to it.) 2. Select the item. Right click and select ACTIVATE. 3. The order screen will populate with the order information. Select OK. 4. Select the Hide Worksheet tab at footer. 5. Select next lab item to be added and repeat steps 2 – 4 for all serial labs. 6. You will ACTIVATE Ten (10) Lab Items in all: 2 are POC (ABG arterial with Lactate and ABG venous) and the rest are sent to the Central Lab for processing. Select “SUBMIT ORDERS” key at footer of screen. 7. Now your CONDITIONAL ORDERS become ACTIVE or PENDING COLLECTION: 8. For POC orders: ABG/Lactic Acid POC ICU and ABG POC Venous ICU, remember to COMPLETE the orders after they have been given to Respiratory personnel. The Central Lab will COMPLETE the lab orders for their specimens once results are available. How to make “Hypothermia Current” your Order Status / Priority Filter What is the “Hypothermia Current” filter? You can specify which orders you want to see by filtering in the Orders tab. This enables you to focus on selected orders by hiding orders that don't meet the filter criteria. For example, there’s no need to view discontinued orders most of the time. On the left side of the window is a panel that enables you to filter your orders as necessary. Because you will see many discontinued orders for Hypothermia patient record, we recommend preparing the Hypothermia Current filter in your profile. . In order to keep your screen view fresh, set up this filter using the following steps 1) Go to Preferences and select Order Review… 2) Select Add New…. 3) Add “Hypothermia Current” as Filter Name in the open text box. 4) Select the following while you hold the “Ctrl” key (see screen shot next page) o o o o o Pending Pending Collection Active Available for activation Final Result Received Select the following while you select “Ctrl” button. 1. Pending 2. Pending Collection 3. Active 4. Available for activation 5. Final Result Received 5) Release Ctrl key and select OK; then select Close. 6) When performing chart checks or to review all orders (including discontinued orders), choose the “ALL” filter. The “ALL” filter will include all order status designations. How to create Reverse Chronological Order (RCO) display format It may be useful to view the most recent orders first under each header. Here’s how you can set up your screen to view orders this way. 1. Select Orders tab and go to Preferences. 2. Select Order Review. 3. Select Display Format tab. Highlight each line i.e. By Department, By Department/Extended etc. and select Reverse Chronological format. 4. Select Close option (above screen shot). 5. Now you have order display as Reverse Chronological so all new orders will display at the top of each category heading e.g. Nursing Hypothermia Protocol for Post Resuscitation Patients – Quick Bedside Reference (Revised April 2010 / PJD) Pt meets enrollment criteria per CC Attending Physician. SCM orders entered by Resident or CC Attending Physician • Obtain STAT EKG and send STAT Labs: CBC, PT/PTT, Chem 7, Mg, Phos, Amylase, Lipase, ALT/AST, CK total, Troponin Ultra, ABG w/Lactate, Venous ABG (HGG for females of childbearing age) • Verify Line Placement: A-line, CVC, Foley, NG or OG tube and 2 Peripheral IVs • Obtain 2 L chilled NSS from Med Refrigerator & replace immediately. • Ensure pt is intubated and sedated (RASS Goal is -4); initiate Neuromuscular Blockade (NMB) for moderate to severe shivering; TOF goal with nerve stimulator is 1 of 4 Twitches. • B-Air Hugger and Fluid Warming Set is available, if needed. • Gaymar III Cooling Unit, 2 sets of hoses, Vest & Leg Wraps at bedside. Induction of Cooling: Goal is 32-34 °C within 4 hours of protocol activation. Notify Resident if target Temp not obtained within 6hr. • Obtain Gaymar III unit. Apply leg and vest wraps to patient. Connect hoses. (See Appendix A on reverse side). • Insert Rectal Probe and connect to Gaymar III Unit. • Use Rapid Cooling Automatic mode for cooling induction. Set Temperature at 34°C • Infuse 2 L of chilled NSS via peripheral IVs using pressure bags to speed infusion. • When NMB is used, Train of Four testing with Nerve Stimulator q 30 min until response is 1 of 4 twitches, then hourly. • Insulin Drip as needed for expected hyperglycemia. (See Insulin Drip Protocol.) • Turn room thermostat to “Off”. Have Respiratory Services turn humidifier “Off”. Important: If the patient’s target cooling temp is overshot, obtain B-AIR Hugger Fluid Warming set and use this tubing to infuse all fluids until such time as patient’s temp is within range. VITALS: BP, HR, MAP, POx, CVP q 15min Temp°C in q 15 min Neuro √ Skin √ & I/O q 1h BG hourly and as needed MEDS: BP GOAL: Target MAP >65 <120; [Expect vasodilator therapy e.g. NTG gtt] Antibiotics as ordered Anti-seizure meds as ordered LABS / Studies: ABG w/lactate, Venous ABG, CBC, PT/PTT, Chem 7, Mg, Phos, CK total, Troponin Ultra, q 6 hours STAT EKG and Daily CXR Maintenance Cooling: Goal is a target temperature of 32 - 34 °C for a period of 24 hours • • • At 34°C, change mode of operation on Gaymar III to Gradual Cooling Automatic mode. Set maintenance temperature to 33°C. Do not make any other changes to mode of operation during this phase. Maintain Insulin Drip as needed per ICU Insulin Drip Protocol. VITALS: BP, HR, MAP, POx, CVP q 1h Temp in °C q 30 min Neuro √ Skin √ & I/O q 1h BG hourly and as needed MEDS: BP GOAL: Target MAP >65 <120; [Expect vasodilator therapy e.g. NTG gtt] Antibiotics as ordered Anti-seizure meds as ordered LABS / Studies ABG w/lactate, Venous ABG, CBC, PT/PTT, Chem 7, Mg, Phos, CK total, Troponin Ultra, q 6 hours EKG every 8 h x 2 and Daily CXR Re-warming: Goal is 36.5°C over a period of 8 hrs. • • • • • • • • Report to resident physician patient is about to be re-warmed. Report CVP reading and recent lab results including STAT Potassium to resident physician before re-warming. Anticipate order to remove all Potassium from maintenance IV Fluids to prevent hyperkalemia with re-warming. Have Neuromuscular Blockade agent discontinued by resident physician when temperature reaches 36°C. At 36.5°C, begin to lighten sedation to a RASS of -2. Increase Gaymar III patient setting cautiously by 0.5°C every 1 – 2 hours using the Gradual Automatic mode. Turn the room thermostat “On”. Have Respiratory Services turn humidifier “On”. When re-warming is complete, turn warming therapy off; continue to monitor all vital signs hourly x 12 hours. Treat fevers with Tylenol 650 mg suppository PR for first 24 hours after re-warming is completed. VITALS: BP, HR, MAP, POx, CVP q 15 min Temp in °C q 15 min Neuro √ Skin √ & I/O q 1h BG hourly and as needed MEDS: BP GOAL: Target MAP >65 <120 [Expect vasopressor therapy e.g. Levophed or Dopa due to vasodilation] Antibiotics as ordered Anti-seizure meds as ordered LABS / Studies Potassium q 4 h ABG w/lactate, Venous ABG, CBC, PT/PTT, Chem 7, Mg, Phos, CK total, Troponin Ultra, q 6 hours Daily CXR Last saved by donnellpC:\Documents and Settings\doquin\Local Settings\Temporary Internet Files\OLK6DA\HT Protocol Bedside Reference FINAL 4 8 10.docdonnellp Page 1 4/9/2010 SCM ORDER SET FOR HYPOTHERMIA PROTOCOL HT Order Set The Hypothermia (HT) Protocol requires the approval of the CC Attending Physician. After patient enrollment, initiate the following SCM order set. The patient must be physically located on the Adult Critical Care Units: 3 Widener A or B or 3 Schiedt. When enrolling a patient, please call Patrick Donnelly @ x5815 and leave the patient’s name and room location. You can also page Patrick at 0240. Hypothermia Therapy EXCLUSION Criteria / Contraindications: • Change in DNAR status post-resuscitation • Pulseless more than 60 minutes during resuscitation effort • Greater than 12 hours since Return of Spontaneous Circulation (ROSC) • GCS Motor Score of 6 • Minimal pre-morbid cognitive status • Other reason for coma: ICH, SAH, etc. • Sepsis as etiology for arrest • Uncontrollable bleeding Non Medication Orders for Nursing: A. Initiate HT Protocol (See Nursing Policy Clinical Guidelines: Hypothermia Therapy for Post Cardiac Arrest Adult Patients and Quick Bedside Reference) 1. Insert Foley. 2. A-line to monitor; NO HEPARIN 3. CVP to monitor; NO HEPARIN 4. Place Gaymar vest and leg wraps on patient; connect to the Gaymar III hypothermia unit (Follow directions from Quick Bedside Reference) 5. Insert disposable rectal probe (place tip no more than 1 ½ inches into anus and secure with tape.) 6. Skin check and care every 1 hour 7. Oral care every 2 hours and as necessary. 8. Reposition patient every 2 hours. 9. Maintain head of bed at greater than 30 degrees at all times. 10. When Neuromuscular Blockade (NMBA) is in use: Train of Four Test every 30 minutes until the target response level of 1 of 4 twitches is observed using a Peripheral Nerve Stimulator, then every 1 hour. 11. □ Sedation Protocol (See Medication Orders) 12. Target RASS score of (-4) during induction and maintenance phases of HT. 13. □ Insulin Drip Protocol (See Medication Orders) 11.25.09 PJD SCM ORDER SET FOR HYPOTHERMIA PROTOCOL B. Cooling Phase: 14. Infuse total of 2 liters chilled 0.9% Na Cl STAT over 30 minutes (rate for each infusion is 4000 mL per hour) via two different peripheral IVs 15. Use Gaymar III Automatic Rapid mode and set target temperature to 34°C. 16. Notify physician if unable to bring patient’s target temperature to 34°C within 6 hours. 17. Vitals during Cooling Phase: BP, HR, MAP, POX, CVP every 15 minutes 18. Temperature in °C every 15 minutes 19. Neuro check every 1 hour 20. I and O every 1 hour 21. Train of Four every 1 hour while on NMBA C. Maintenance Phase: 22. At 34°C, use Gaymar III Automatic Gradual mode and set target temperature at 33 °C. This is the beginning of the Maintenance phase. 23. Maintain target range of 32 – 34°C for 24 hours during this Maintenance phase. 24. Vitals during Maintenance: BP, HR, MAP, POX, CVP every 1 hour 25. Temperature in °C every 30 minutes 26. Neuro check every 1 hour 27. I and O every 1 hour 28. Train of Four every 1 hour while on NMBA D. Re-warming Phase: 29. After 24 hours of Maintenance temperature, begin Re-warming phase. 30. Obtain STAT Potassium level before re-warming. 31. Report Potassium level, CVP and BP measurements to resident physician to determine IV Fluid rate of 0.9 NSS. 32. Increase temperature to 36.5°C by 0.5 °C every 1 hour using the Gaymar III Automatic Gradual mode. 33. Discontinue NMBA when in use once patient temperature reaches 36°C. 34. Begin to taper sedation when patient temperature reaches 36.5 °C. 35. During Re-warming phase and after the NMBA is discontinued, the target RASS score is (-2). E. Normothermia Phase: 36. Maintain normothermia (Temp > 36.5°C and < 38°C) for a period of 24 hours after successful Re-warming. 37. Monitor patient’s temperature using the Monitor mode of the Gaymar III cooling unit. 38. Use Tylenol (see medication orders) to maintain normothermia for 24 hours following re-warming. 39. If patient’s temperature > 37°C after 24 hours of Tylenol use, use cooling blanket to treat patient’s temperature. 11.25.09 PJD SCM ORDER SET FOR HYPOTHERMIA PROTOCOL F. Labs/Studies: Please note: whenever a patient’s temperature is less than 32°C or greater than 40°C, report temperature measurement to the lab for temperature corrected values. 40. STAT LABS: ABG, CBC with Differential, PT/PTT/INR, Chem 7, Mg, Phos, CK, troponin I, Lactate, Amylase, Lipase and AST, ALT 41. STAT Beta HCG for all female patients of child bearing years. 42. Serial Labs for Cooling, Maintenance and Re-warming phases: ABG, Central Venous O2 Saturation, PT/PTT/INR, Chem 7, Ca, Mg, Phos, CK, Troponin I, Lactate and CBC with Differential every 6 hours. 43. STAT Potassium level before re-warming begins.. 44. Finger-stick Blood Glucose hourly 45. Daily portable CXR. 46. EKG q 8 hours x 3 G. Nutrition: 47. NPO 48. OG or NG tube to low intermittent wall suction H. Medication Orders: a. Neuromuscular Blockage Agents (NMBA): i. Cisatracurium IV: Initiate Cisatracurium before initiating cooling. Dosing recommendation: Bolus dose 0.15 mg/kg; infusion: 200mg Cisatracurium in 250ml D5W. Begin infusion of 1 – 3 mcg/kg/min after initial bolus. ii. Vecuronium IV: Dosing recommendation: Bolus dose is 0.05 – 0.1 mg/kg over 1 – 2 minutes; infusion: 20 mg Vecuronium in 100 ml D5W. Begin infusion of 0.8 -1.7mcg/kg/min 20 – 40 minutes after initial bolus. b. Sedation Orders: Refer to ICU Sedation Protocol c. Vasodilator: (select one) □ Nitroglycerine IV 50mg in 250ml D5W in mcg/min; maintain MAP greater than 65and less than 120. □ Esmolol IV 2500 mg in 250 ml NSS in mcg/kg/min; maintain MAP greater than 65and less than 120. Use with tachycardia or acute ischemia/MI without LV dysfunction. Initiate 50 mcg/kg/min and increase by 50mcg/kg/min to a max rate of 300 mcg/kg/min for a heart rate of less 100. d. Vasopressor: (Norepinephrine: 4 mg in 250 ml D5W in mcg/min); maintain MAP greater than 65 and less than 120. e. Insulin Protocol: If 2 consecutive finger-stick glucose results are greater than 150, begin Insulin Protocol. f. DVT Prophylaxis: i. □ Heparin 5000 units SubQ every 8 hour ii. □ Intermittent Compression Stocking after Re-warming completed. g. GI Prophylaxis: i. Famotidine 20 mg via NG/OG tube or IV every 12 hrs. h. Meperidine for shivering once NMBA is discontinued: Meperidine 12.5 – 25 mg every 4 – 6 hours IVP (not to exceed 100mg) can be used to treat shivering once the NMBA has been stopped. NOTE: do not use in renal failure, oliguria, or in patients taking an MAO inhibitor, Buspirone or SSRI. 11.25.09 PJD SCM ORDER SET FOR HYPOTHERMIA PROTOCOL i. Opthalmic Lubricant Ointment: 1 application to both eyes every 2 hours for prophylaxis. j. Tylenol (Select one) □ 650 mg suppository PR every 4 hours for Temp greater than 38°C □ Tylenol liquid 160 mg/5ml (Give 650 mg = 20 ml) via Orogastric or DHT for Temp greater than 38°C 11.25.09 PJD Set-up Procedure for INDUCTION of Hypothermia Therapy: • Fill water reservoir to green line with distilled water. • Temperature probe should be inserted into patient at this time using a disposable patient probe with reusable adapter cable • Apply the vest wrap to the patient. Body wraps are designed to be in direct contact with the skin. Connect vest wrap to fist set of gray hoses; connect hoses to machine. • Apply the leg wraps to the patient. Body wraps are designed to be in direct contact with the skin. • Interconnect the leg wraps using one tube from each leg wrap. Connect the remaining leg wrap tubing to the 2nd gray hose set. Connect 2nd set of hoses to machine. • Turn machine ON. • Machine will prompt you to select a Mode. Press the button for Auto Mode. The machine will default to RAPID setting. • Set the Temperature to 34 °C. Continue to observe wraps to ensure no kinks nor folds and no obstruction to the water flow. (See below). Achieving and Maintaining Patient Target Temperature (MAINTENANCE Phase) • When 34 °C has been reached, change the machine setting to GRADUAL by pressing the AUTO button twice. • • Decrease temperature setting to 33 °C. Continue maintenance for 24 hours. Don’t make any adjustments to the set temperature of 33 °C since the Medi- Therm will continue to adjust the water temperature when necessary in order to achieve and maintain patient set point temperature. Important: DO NOT READJUST the machine. There will then be an interval between ½ h - 1 hour of minimal patient temperature overshoot. Patient temperature may fluctuate approximately 0.6° until the water temperature stabilizes. Active RE-WARMING Phase The Rapr-Round body wraps should remain on the patient. Use Auto GRADUAL Mode to control body wrap temperature. Adjust the patient set point temperature .5° C every 1 - 2 hours as necessary to increase the patient temperature to 36.5°C over 8 hours. This gradual increase will help to prevent the patient from being re-warmed too quickly. After Re-warming is completed, press Monitor mode to continue to display patient temperature. To Check the Flow though the Vest and Leg Wraps: • Disconnect one gray hose set from the machine; if flow path is patent, alarm will not sound; reconnect. • Disconnect 2nd set of gray hoses from machine; if flow is patent, alarm will not sound; reconnect. • If alarm continues, remove from service. Contact BioMEd Dept. Obtain new cooling unit. In this box is a diagram of the control board for the Gaymar III cooling unit. (See hard copy for actual diagram). Where can I find more information? Questions and Support? For information on cardiac arrest support groups: Please feel free to ask the doctors and nurses if you have any further questions regarding your loved one’s post-arrest care, including TH. -Sudden Cardiac Arrest Association Therapeutic Hypothermia www.suddencardiacarrest.org Support is available from our chaplain services or social services. For information on cardiac arrest and therapeutic hypothermia: -Center for Resuscitation Science Support from family and friends may also be helpful. www.med.upenn.edu/resuscitation For information on cardiac arrest, CPR and current guidelines: -American Heart Association www.heart.org It is also important to remember to take care of yourself while waiting for your loved one to recover. Please remember to get plenty of rest, sleep and proper nutrition. This process will be a marathon, not a sprint. Created by: Marion Leary RN, BSN , Shirley McKinney MSN, CCRN Updated: June 15, 2010 Caring for a loved one during hypothermia. Therapeutic Hypothermia What is Therapeutic Hypothermia? Therapeutic hypothermia (TH) is considered an important therapy for a comatose survivor of cardiac arrest—a patient whose heart stopped beating, was restarted during cardiopulmonary resuscitation (CPR), and who remains minimally responsive immediately after the event. It is endorsed by the American Heart Association and is performed by lowering the body temperature to 32-34ºC (approximately 90 to 93ºF). Normal body temperature is 98.6º F or 37ºC. How Does Hypothermia Help? TH works by protecting the brain and other vital organs. It lowers oxygen requirements, decreases swelling, and limits the release of toxins, which can cause cells to die. TH has been shown to improve neurological outcomes and increase survival in patients who remain in a coma after successful CPR. What are the Risks to Cooling? There are few risks associated with mild TH. On the other hand, this therapy offers important benefits to survival and neurological recovery. Your loved one will be monitored closely by the health care team and side effects will be quickly managed. What to Expect? Close monitoring will be provided in the intensive care unit (ICU). When the patient first arrives in the ICU, please allow at least 90 minutes for the doctors and nurses to provide immediate necessary care. Your loved one will be kept unconscious with sedation and other medications and will be on a breathing machine. Vital signs such as temperature, blood pressure and heart rate will be continuously monitored. To provide the highest level of care during TH, many blood tests and procedures will be performed during the first 24-48 hours. How is TH initiated and maintained? The cooling process can be performed in a variety of different ways including: chilled intravenous fluids to initiate TH; cooling wraps applied to your loved one’s chest and legs to maintain body temperature at 32-34ºC; and ice packs placed on the groin, neck, or under the arms. Medication will be given, if necessary, to prevent shivering, which can slow the cooling process. When Should Cooling Begin and How Long Will it Last? Cooling should began as soon as possible after a patient has survived a cardiac arrest. The therapy will be continued for approximately 24 hours. Your loved one will be re-warmed slowly over roughly 12 hours until the body temperature returns to normal (37°C). When the re-warming process nears completion, some of the sedating medications will be turned off. Recovery: Recovery occurs on an individual basis. Some patients wake up very quickly after re-warming is complete. Some patients may take longer than 72 hours to begin waking up. It is important to remember that cardiac arrest is a very critical illness, and there is no guarantee that recovery will be possible. In general, no decisions should start to take place until at least 72 hours from the time your loved one’s heart was restarted and re-warming complete. Hypothermia Protocol (Adult) Order Set (Revised Dec 2011) FEATURES of Redesign: • • • All relevant orders are pre selected Providers can only enter one Phase’s orders at each session. Organized design to pick necessary orders easily. Discontinuing Orders for a given Phase: You are required to discontinue previous phase orders prior to placing next phase orders. Example: Going from Induction & Cooling to Maintenance phase: • • Look for (Induction & Cooling) Nursing Orders and select one of them Right Click and select “Discontinue/Cancel” option You will next see all Nursing Orders placed from Hypothermia Protocol Order Set. But only the (Induction and Cooling) nursing orders are pre-selected to Discontinue/Cancel. • Please verify the contents and select “OK” to discontinue. Now you are ready to enter the next Phase (Maintenance). Going from Maintenance to Re-warming and/or Re-warming to Post-Therapy Phases: • • • Look for (Maintenance) or (Re-warming) Nursing orders. Select one as is appropriate. In this example, we’re moving from Maintenance to Re-warming. Right Click and select “Discontinue/Cancel” option You will see now the selected phased nursing orders in the new window (in this example Maintenance) and all nursing orders are pre-selected to discontinue. • Please verify the contents and select “OK” to discontinue. Follow these steps whenever you move between phases of the HT Protocol Order Set. Good luck!