Original Article

Community-Based Application of Mild Therapeutic Hypothermia for Survivors of Cardiac Arrest

Authors: John Prior, DO, Mary Lawhon-Triano, CRNP-C, David Fedor, DO, Vincent J. Vanston, MD, Roger Getts, DO, Raymond A. Smego, Jr., MD, MPH

Abstract


Objective: To demonstrate that the application of therapeutic hypothermia is technically feasible in a community-based setting.


Background: Implementation of therapeutic hypothermia for survivors of cardiac arrest in the United States has been slow, at least partially because of the perception that this therapy is technically difficult, especially at the community level.


Study Design: Retrospective cohort study with historical controls.


Methods: At our three community hospitals and after return of spontaneous circulation (ROSC), survivors of cardiac arrest were treated with therapeutic hypothermia using ice and cooling blankets or suits in order to cool patients to 32°C–34°C within 4 hours to achieve goal temperature within 8 hours and to maintain goal temperature for 24 hours.


Results: Beginning in 2004, 44 survivors of cardiac arrest were managed with therapeutic hypothermia. The mean time from ROSC to initiation of therapeutic hypothermia was 2.8 hours (range, 0.2–7.8 hours), the mean time from ROSC to goal temperature was 7.2 hours (range, 0.8–15.1 hours), and the mean time maintained at goal temperature was 24.5 hours (range, 9–28 hours). Once patients achieved goal temperature, 4.4% of the temperature readings were above 34°C, reflecting undercooling, while 16.4% of the readings were below 32°C, indicative of overcooling. Overall survival until hospital discharge with good neurologic outcome was 43%, compared to only 13% (P < 0.001) among selected controls. There were no major complications directly attributable to the induction of hypothermia or rewarming.


Conclusion: A simple protocol of mild therapeutic hypothermia using locally available resources is technically feasible and safe in a community-based setting.



This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Polderman KH. Hypothermia and neurological outcome after cardiac arrest: state of the art. Eur J Anaesthesiol Supp 2008;42:23–30.
 
2. Wolff B, Machill K, Schumacher D, et al. Early achievement of mild therapeutic hypothermia and the neurologic outcome after cardiac arrest. Int J Cardiol 2009;133:223–228.
 
3. Bruel C, Parienti JJ, Marie W, et al. Mild hypothermia during advanced life support: a preliminary study in out-of-hospital cardiac arrest. Crit Care 2008;12:R31.
 
4. Hay AW, Swann DG, Bell K, et al. Therapeutic hypothermia in comatose patients after out-of-hospital cardiac arrest. Anaesthesia 2008;63:15–19.
 
5. Macdonald N, Moonesinghe SR. Therapeutic hypothermia after cardiac arrest. Br J Hosp Med (Lond) 2007;68:397.
 
6. Tiainen M, Poutiainen E, Kovala T, et al. Cognitive and neurophysiological outcome of cardiac arrest survivors treated with therapeutic hypothermia. Stroke 2007;38:2303–2308.
 
7. Froehler MT, Geocadin RG. Hypothermia for neuroprotection after cardiac arrest: mechanisms, clinical trials and patient care. J Neurol Sci 2007;261:118–126.
 
8. Belliard G, Catez E, Charron C, et al. Efficacy of therapeutic hypothermia after out-of-hospital cardiac arrest due to ventricular fibrillation. Resuscitation 2007;75:252–259.
 
9. Laish-Farkash A, Matetzky S, Kassem S, et al. Therapeutic hypothermia for comatose survivors after cardiac arrest. Isr Med Assoc J 2007;9:252–256.
 
10. Arrica M, Bissonnette B. Therapeutic hypothermia. Semin Cardiothorac Vasc Anesth 2007;11:6–15.
 
11. Holzer M, Bernard SA, Hachimi-Idrissi S, et al; Collaborative Group on Induced Hypothermia for Neuroprotection After Cardiac Arrest. Hypothermia for neuroprotection after cardiac arrest: systematic review and individual patient data meta-analysis. Crit Care Med 2005;33:414–418.
 
12. Bernard S. Therapeutic hypothermia after cardiac arrest: now a standard of care. Crit Care Med 2006;34:923–924.
 
13. Kennedy J, Green RS, Stenstrom R; CAEP Critical Care Committee. The use of induced hypothermia after cardiac arrest: a survey of Canadian emergency physicians. CJEM 2008;10:125–130.
 
14. Brooks SC, Morrison LJ. Implementation of therapeutic hypothermia guidelines for post-cardiac arrest syndrome at a glacial pace: seeking guidance from the knowledge translation literature. Resuscitation 2008;77:286–292.
 
15. Suffoletto BP, Salcido DD, Menegazzi JJ; National Association of Emergency Medical Services Physicians. Use of pre-hospital-induced hypothermia after out-of-hospital cardiac arrest: a survey of the National Association of Emergency Medical Services Physicians. Prehosp Emerg Care 2008;12:52–56.
 
16. Oksanen T, Pettilä V, Hynynen M, et al; Intensium Consortium Study Group. Therapeutic hypothermia after cardiac arrest: implementation and outcome in Finnish intensive care units. Acta Anaesthesiol Scand 2007;51:866–872.
 
17. Holzer M, Sterz F; Hypothermia After Cardiac Arrest Study Group. Therapeutic hypothermia after cardiopulmonary resuscitation. Expert Rev Cardiovasc Ther 2003;1:317–325.
 
18. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557–563.
 
19. Langhelle A, Nolan J, Herlitz J; 2003 Utstein Consensus Symposium. Recommended guidelines for reviewing, reporting, and conducting research on post-resuscitation care: the Utstein style. Resuscitation 2005;66:271–283.
 
20. A randomized clinical study of a calcium-entry blocker (lidoflazine) in the treatment of comatose survivors of cardiac arrest. Brain Resuscitation Clinical Trial II Study Group. N Engl J Med 1991;324:1225–1231.
 
21. Raina KD, Callaway C, Rittenberger JC, et al. Neurological and functional status following cardiac arrest: method and tool utility. Resuscitation 2008;79:249–256.
 
22. Fonarow GC. Beta-blockers for the post-myocardial infarction patient: current clinical evidence and practical considerations. Rev Cardiovasc Med 2006;7:1–9.
 
23. O'Connor CM. The new heart failure guidelines: strategies for implementation. Am Heart J 2007;153(4 suppl):2–5.
 
24. Søreide E, Sunde J. Therapeutic hypothermia after out-of-hospital cardiac arrest: how to secure worldwide implementation. Curr Opin Anaesthesiol 2008;21:209–215.
 
25. Laver SR, Padkin A, Atalla A, et al. Therapeutic hypothermia after cardiac arrest: a survey of practice in intensive care units in the United Kingdom. Anaesthesia 2006;61:873–877.
 
26. Merchant RM, Soar J, Skrifvars MB, et al. Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest. Crit Care Med 2006;34:1935–1940.
 
27. Abella BS, Rhee JW, Huang KN, et al. Induced hypothermia is underused after resuscitation from cardiac arrest: a current practice survey. Resuscitation 2005;64:181–186.
 
28. Wolfrum S, Radke PW, Pischon T, et al. Mild therapeutic hypothermia after out-of-hospital cardiac arrest: a nationwide survey on the implementation of the ILCOR guidelines in German intensive care units. Resuscitation 2007;72:207–213.
 
29. Majersik JJ, Silbergleit R, Meurer WJ, et al. Public health impact of full implementation of therapeutic hypothermia after cardiac arrest. Resuscitation 2008;77:189–194.
 
30. Friberg H, Nielsen N. Hypothermia after cardiac arrest: lessons learned from national registries. J Neurotrauma 2009;26:365–369.
 
31. Schefold JC, Storm C, Joerres A, et al. Mild therapeutic hypothermia after cardiac arrest and the risk of bleeding in patients with acute myocardial infarction. Int J Cardiol 2009;132:387–391.
 
32. Kilgannon JH, Roberts BW, Stauss M, et al. Use of a standardized order set for achieving target temperature in the implementation of therapeutic hypothermia after cardiac arrest: a feasibility study. Acad Emerg Med 2008;15:499–505.
 
33. Arrich J; European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group. Clinical application of mild therapeutic hypothermia after cardiac arrest. Crit Care Med 2007;35:1041–1047.
 
34. Oddo M, Schaller MD, Feihl F, et al. From evidence to clinical practice: effective implementation of therapeutic hypothermia improve patient outcome after cardiac arrest. Crit Care Med 2006;34:1865–1873.
 
35. Haugk M, Sterz F, Grassberger M, et al. Feasibility and efficacy of a new non-invasive surface cooling device in post-resuscitation intensive care medicine. Resuscitation 2007;75:76–81.
 
36. Busch M, Soreide E, Lossius HM, et al. Rapid implementation of therapeutic hypothermia in comatose out-of-hospital cardiac arrest survivors. Acta Anaesthesiol Scand 2006;50:1277–1283.
 
37. Barros RC, Branco LG, Cárnio EC. Evidence for thermoregulation by dopamine D1 and D2 receptors in the anteroventral preoptic region during normoxia and hypoxia. Brain Res 2004;1030:165–171.
 
38. Ruttmann E, Weissenbacher A, Ulmer H, et al. Prolonged extracorporeal membrane oxygenation-assisted support provides improved survival in hypothermic patients with cardiocirculatory arrest. J Thorac Cardiovasc Surg 2007;134:594–600.
 
39. Flint AC, Hemphill JC, Bonovich DC. Therapeutic hypothermia after cardiac arrest: performance characteristics and safety of surface cooling with or without endovascular cooling. Neurocrit Care 2007;7:109–118.
 
40. Hoedemaekers CW, Ezzahti M, Gerritsen A, et al. Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients: a prospective intervention study. Crit Care 2007;11:R91.
 
41. Merchant RM, Abella BS, Peberdy MA, et al. Therapeutic hypothermia after cardiac arrest: unintentional overcooling is common using ice packs and conventional cooling blankets. Crit Care Med 2006;34:S490–S494.
 
42. Kämäräinen A, Virkkunen I, Tenhunen J, et al. Pre-hospital induction of therapeutic hypothermia during CPR: a pilot study. Resuscitation 2008;76:360–363.
 
43. Våga A, Busch M, Karlsen TE, et al. A pilot study of key nursing aspects with different cooling methods and devices in the ICU. Resuscitation 2008;76:25–30.
 
44. Polderman KH. Application of therapeutic hypothermia in the intensive care unit. Opportunities and pitfalls of a promising treatment modality–part 2: practical aspects and side effects. Intensive Care Med 2004;30:757–769.
 
45. Alam HB, Rhee P, Honma K, et al. Does the rate of rewarming from profound hypothermic arrest influence the outcome in a swine model of lethal hemorrhage? J Trauma 2006;60:134–146.
 
46. Maxwell WL, Watson A, Queen R, et al. Slow, medium, or fast rewarming following post-traumatic hypothermia therapy? An ultrastructural perspective. J Neurotrauma 2005;22:873–874.