Protocol for therapeutic hypothermia after cardiac arrest

Protocol for therapeutic hypothermia after cardiac arrest

2004年11月7日by Ri 蔡銘駿

1. Goal:

To reach core temperature of 32~34℃ within 4 hours after return of spontaneous circulation and maintain for 24 hours

2. Inclusion criteria for the patients:

  (1) Cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia.

  (2) The interval between the onset of cardiac arrest and the initiation of ACLS should be 5~15 minutes.

  (3) Patients who are comatose with inappropriate response to verbal commands and  GCS< 9.

  (4) Patients who are intubated and ventilated.

  (5) Age between 18~75 years old.

3. Exclusion criteria for the patients:

  (1) CPR for more than 60 minutes.

  (2) Pregnant

  (3) Coma due to other causes such as trauma

  (4) Patients who are unstable in spite of IV fluids and inotropic agents support

(5) Patients with preexising coagulopathy or with clinical evidence of bleeding.

4. Initial sedation and muscle relaxation:

Prior to cooling to prevent shivering. Continue the medications during the entire cooling and rewarming phases.

(1)   Fentanyl

   1~2 μg/kg/hr, IV infusion (conc.: 50μg/mL)

  (2) Midazolam

     0.1~0.2 mg/kg/hr, IV infusion (conc.: 1mg/mL)

  (3) Pancuronium

0.1 mg/kg initially, followed by 0.01mg/kg/hr

5. Temperature monitoring:

         continuous core temperature monitor by Swan-Ganz catheter, Foley temp. probe, rectal temp. probe.

6. Steps for the cooling process:

  (1) Turn off the heater on the ventilator humidifier.

  (2) Wrap the patient’s hands and feet in dry tower.

  (3) Administer IV infusion of 4℃ lactate ringer solution 30ml/kg over 30 minutes.

  (4) Maintain ice packs around head, axilla, and groin to keep the temperature

within 32-34℃ and keep it for 24 hours.

 ( For ECMO patients, keep heater-cooler temperature at 33℃ for 24 hours)

(5) Monitor skin carefully for the evidence of frostbite.

  (6) Hold ice packing if the temperature falls below 32 ℃. 

7. General condition maintainace:

  (1) Mean arterial pressure between 80~100 mmHg.

  (2) Administer IV fluids that are free of dextrose to avoid hyperglycemia.

8. Passive rewarming:

  (1) Rewarm patients passively by removing all the cooling methods

  (2) Cover patients with dry towel.

  (3) Use heated-air blanket for help if the temperature doesn’t get back to normal within 6 hours.

  (3) Discontinue the medications for sedation and muscle relaxation after the temperature get back to normal.

 (for ECMO patients, increase heater-cooler temperature 1℃/hr up to 38℃)

 (when core temperature has gone to 36℃, begin ventilator humidifier)

8. Reference

  (1) The Hypothermia After Cardiac Arrest Study Group: Mild therapeutic hypothermia to improve the neurological outcome after cardiac arrest. NEJM  2002, 346: 549-556

  (2) Bernard SA, Gray TW, Buist MD, et al: Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. NEJM 2002, 346: 557-563

  (3) Bernard SA, Buist MD, Monteiro O, et al: Induced hypothermia using large volume ice-cold intravenous fluid in comatse survivors of out-of-hospital cardiac arrest: A preliminary report. Resuscitation 2003, 56: 9-13

  (4) http://www.show.scot.nhs.uk/rie-icu/downloads/therapeutic%20hypo.1.doc

  (5) http://www.lhsc.on.ca/critcare/icu/cctc/procprot/hypo0104.pdf