CRITICAL CARE POLICY AND PROCEDURE MANUAL Page 1 of 10 Title: Adult Therapeutic Hypothermia Policy No. CC-8.03 Joint Commission Chapter/Section: Effective Date: June, 2014 Source (e.g. document, award, or committee, etc.) A. Bukhari, MD, Chief, Pulmonary, Critical Care Critical Care Committee Cross-Referenced Policy No: I. POLICY: Publication Status: New X Revised 8/13 Reviewed Neuromuscular blockade CC-14.01 The Code Chill protocol will be activated upon identification of a patient who is a potential candidate for the application of Adult Therapeutic Hypothermia Post Cardiac Arrest. The order will be provided by an attending physician who is called upon to evaluate a patient in the Emergency Department or adult inpatient areas. II. PURPOSE: This policy defines the procedure for the application of Adult Hypothermia Post Cardiac Arrest. The patients must fit the inclusion and exclusion criteria as defined in the proceeding body of this document. III. SCOPE: The scope of this policy includes the Emergency Department, Adult ICU and licensed independent practitioners. IV. DEFINITIONS: A. ADULT THERAPEUTIC HYPOTHERMIA Hypothermia is a state of body temperature below normal in a homoeothermic (warmblooded) organism. Therapeutic hypothermia is administered in a controlled way, as in contrast to accidental hypothermia. With controlled hypothermia, it is possible to avoid possible defense mechanisms like shivering or catecholamine release. The multifactorial protective action of hypothermia includes the protection of lipid membranes fluidity, the slowing of destructive enzymatic processes and the reduction of oxygen needs without impairing microvasculatory blood flow in low-flow regions during reperfusion after ischemia. Additionally, therapeutic hypothermia inhibits lipid peroxidation, attenuates brain edema, and reduces intracellular acidosis 1
Cold saline is defined as 0.9% sodium chloride IV at a temperature range from 36 to 46 degrees F for therapeutic hypothermia. The cold saline is stored in a medication refrigerator. B. CODE CHILL TEAM MEMBERS Code Chill employs a collaborative approach whose team members can include: In the Emergency Department: ED physician and Licensed Independent Practitioner (LIP) ED Nursing Team ED Manager or Nursing supervisor Respiratory therapist ICU resident and/or Critical Care Attending In the Adult ICU: ICU Resident and/or Critical Care Attending ICU Nurse ICU Assistant Nurse Manager, or Charge nurse ICU Manager or Nursing supervisor Respiratory therapist C. POPULATION OR CLINICAL CONDITION Inclusion Criteria: Allcriteriamustbemet. Patient age between 18 to 75 years of age Return of Spontaneous Circulation (ROSC) within 60 minutes of starting CPR Mechanically ventilated Comatose/unresponsive to commands/ no purposeful movement (Glascow coma scale less than 8) Exclusion Criteria: One (or more) criteria must be met. Pulseless greater than 60 minutes DNR status Major head trauma Coagulopathy Uncontrolled hemodynamically significant dysrhythmia History of cryoglobulinemia Greater than 6 hours lapsed from time of return of spontaneous circulation (ROSC). Relative Contraindications: Pregnancy Major surgery within 14 days Baseline cognitive function severely impaired End stage terminal illness Multi organ dysfunction Sepsis prior to cardiac arrest Page 2 of 10
V. PROCEDURE: The ED Attending Physician/Critical Care Attending will: 1. Evaluate the patient for eligibility. The ED RN/ICU RN will: 1. Initiate Code Chill protocol A. In The Emergency Department (ED) Setting 1. The ED staff will evaluate the patient for eligibility for cooling therapy. 2. If eligible the Code Chill protocol will be initiated by calling 112, which will send an overhead page in which the operator will state Code Chill and identify the location. 3. The overhead Code Chill promptly secures an ICU bed for the patient. 4. Appropriate ICU personnel will respond to Code Chill in the ED. 5. The ED staff will initiate cooling protocol with cold saline and ice packs as per orders. Ensure that there is a barrier between the skin and the ice packs to prevent skin injury. Remove the ice packs once the goal temperature is reached. 6. The ED nurse will conduct a thorough skin assessment on arrival to identify potential deep tissue injury or other pressure areas present upon admission and document findings. 7. The ED provider will determine if patient requires emergent cardiac intervention; if so, the team initiates the CODE MI protocol. B. Cardiac Catheterization Lab 1. Continue cooling protocol if already initiated C. Intensive Care Unit ( ICU) Initial Cooling Phase (Use the Gaymar Medi-Therm III MTA 7900): 1. Once hypothermia eligibility is confirmed, and hypothermia orders are obtained from the physician, gather the following materials. Internal temperature monitoring device by rectal probe. Approved cooling device Peripheral nerve stimulator Nasogastric tube Lubricant 60 ml catheter-tip syringe Rectal thermometer Line cart for central line &/or arterial line insertion Cold normal saline as ordered. Obtain cold saline from medication refrigerator. 2. Insert two (2) peripheral large bore IVs, 18 gauge or larger, as ordered if a central line is not present, as ordered. 3. Obtain baseline temperature and follow all monitoring parameters as ordered for TH on the TH Flow Sheet in the including: vital signs, core temperature, oxygen saturation, urine output and shivering scale. 4. Sedation is initiated and titrated to prevent shivering prior to application of cooling management system per the sedation order set (Form #) and the orders of the LIP. 5. Obtain laboratory specimens ordered. Alert the lab that the patient is a Code Chill patient and that the ABG is to be tested at the patient s temperature at the time the ABG was drawn. 6. Suspend all attempts at ventilator weaning during the cooling and rewarming phases of Code Chill. 7. Infuse cold normal saline IV as ordered. Page 3 of 10
8. Initiate surface cooling device and attached cooling wraps on lower extremities and trunk of the body per manufacturer s instructions. 9. Activate cooling system with temperature set to 33 degrees C (91.4F) as goal temperature. Utilize additional surface cooling devices as appropriate to reach target temperature. 10. Set thermostat in the patient s room to 65 degrees F during TH. 11. Respiratory therapist should turn temperature on ventilator heater to off and use a moisture exchange filter. 12. Monitor and document vital signs per protocol (every 15minutes for 1 hour then every 30 minutes for 2 hours then per ICU protocol. Monitor for arrhythmias (most common bradycardia). If significant dysrhythmias, hemodynamic instability or bleeding develops, MD should be notified immediately. 13. RN will perform hourly assessments of skin integrity & catheter sites, assess for signs of tissue intolerance. Skin will be assessed under the pads every 4 hours (open wraps to fully assess skin). 14. Document and trend water temperature hourly 15. Maintain cooling process for any patient transports. Immediately reportable conditions during hypothermia: Dysrhythmias Seizure Bleeding A QT interval greater than 500 milliseconds (0.5 seconds) or an increase in the QT interval of 60 milliseconds (0.06 seconds) from the patient s baseline QT interval. D. Management to Prevent / Control Shivering: Refer to Policy CC-14.01 (Antianxiety, Analgesic & Paralytic use) 1. If paralytic is ordered for management of shivering prior to administration, an order must be obtained for sedation. 2. Follow the orders in the Analgesic and Paralytic order set. 3. Attempt to titrate paralytic off when goal of 33 degrees C (92 degrees F) is reached per policy if the patient is not shivering. Rewarming Phase 1. When patient reaches set goal of 33 degrees C (92 degrees F) for 24 hours begin rewarming at 0.3 degree C/hour (0.54 degrees F/hour) not to exceed greater than 1 degree C /hour) to target goal. Use the Moderate setting on the Gaymar Medi-Therm III MTA 7900 machine. 2. Keep probe in place and surface garments on until patient is normothermic; then titrate per sedation/analgesia protocol. 3. Turn on ventilator heater and set to 37 degrees Celsius (98.6 degrees Fahrenheit). 4. Maintain normothermia for an additional 24 hours once patient s core temperature reaches 36 degrees Celsius (96.8 degrees Fahrenheit). If the patient s temperature is equal to or greater than 37.5 degrees Celsius (99.5 degrees Fahrenheit), notify the LIP for further orders. DOCUMENTATION 1. Initiation, ongoing and termination of protocol. 2. Baseline and hourly patient temperature and route on the hypothermia therapy flow sheet. 3. Trend water temperature 4. Presence of shivering 5. Skin Integrity Page 4 of 10
VI. REFERENCES: Holzer, Micheal, and Behringer, Wilhelm, Therapeutic hypothermia after cardiac arrest and myocardial infarction, Best Practices & Research Clinical Anesthesiology, vol. 22, No. 4, pp. 711-728, 2008. doi:10.1016/j.bpa.2008.02.001, available online at http://www.sciencedirect.com. Morris, S. (2011). 2010 BLS and ACLS Guideline Changes: Post-Cardiac Arrest Syndrome and Therapeutic Hypothermia. Canadian Journal of Cardiovascular Nursing, 21 (3), 3-5. Young-Min, K., Hyeon-Woo, Y., Seung-Hee, J., Mary Lou, K., & Clifton WC. (n.d.). Clinical paper: Does therapeutic benefit adult cardiac arrest patients. Wang, C., Yang, S., Lee, C., Lin, R., Peng, M., & Wu, C. (2013). Therapeutic hypothermia application vs. standard support care in post resuscitated out of hospital cardiac arrest patients. American Journal of Emergency Medicine, 31 (2), 319-325.doi:10.1016/j.ajema.2012.08.024. Approved by: Signature - Elizabeth Wykpisz, RN, MSN, MBA, NEA-BC Signature Sharon Haskins, MSN, MBA, RN-BC, NE-BC CNO/Vice President Patient Care Services 6/4/14 Title Date Director, Critical Care & Adult Med/Surg 6/4/14 Title Date Origination Date: 4/18/2013 Supersedes Date(s): 6/4/14 Reviewed Date: Revised Date: 5/2014 CC-8.03 Page 5 of 10
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