Transcript Video 2024 AACN Presentations See presentations from Mary Kay Bader AACN 2024. Welcome to our sunrise session for Wednesday this morning. I have the pleasure of introducing for you, Miss Mary Kay Bader, who has started with her uh clinical nurse specialist in Neuro Critical Care has moved on to uh fellow of both American Heart Association Society of Critical Care Medicine and Neuro Critical Care Society, First Nursing, past president of Neuro Critical Care Society and now a member of the World Federation of Nursing. If you've not gotten a chance to listen to one of her talks today, this is one of the few people who actually walk their talk. You want to build a multidisciplinary committee, watch what Mary Kay built. You want people aligned in how to assess and implement best practice. Watch what Mary Kay has created. If you want to look at your data and see the impact that you make, there will be no burnout in nursing, prepare to be inspired. Welcome. Take it away. Mary Kay is not. Thanks Colleen. I guess I'm, I'm, I'm gonna be tied to the podium because of the, the speaker and there are lots of seats up here if anybody needs a seat. So it's an honor to be here with you. I am from Providence Mission Hospital in Mission Viejo, California. Uh we are in Orange County and I don't know about you, but this morning when I left the hotel and walked across the street, I thought, oh, I felt like one of those athletes that gets immersed in an ice tub and then comes back out, gets warm when you walk through the door. So welcome. Uh First off, my email is on the slide beer MK at aol.com. Yes. AOL someone still has an AOL dress. That's me. It's been faithful to me for all these years. Uh If you want any protocols, guidelines, articles, um you, I can send them to you, but also there'll be a QR code. The team at BD also has uh resources to share with you. So, between the, the BD company and me, uh we will be able to meet your needs, I think. All right. So disclosures uh I uh BD is sponsoring this talk and um as mentioned, I'm currently on the board of directors of the World Federation of Critical Care Nurses. So this morning, we're, we have two main objectives, identify TT M studies and professional guidance released in the last year for protocol review and develop an assessment workflow decision that supports targeted patient therapy using objective data to reduce bias and optimize recovery. First and foremost, I need to hear from you how many of you are doing TT M for post cardiac rest. Great. How many stopped tt M so a handful. It's a fair question. A fair answer. How many of you target just normal theia? How many target? 33? 36? Ok. I think that after the talk, you might want to ponder the decision of whether 33 or 36 or 37 is the right choice. And I'm going to take you through the journey of the literature. One of the keys to understanding and, and reading studies. I don't have a phd, I'm a old master's nurse. Uh I, I'm a clinical nurse specialist, but I learned how to read studies. And one of the things you always have to do is you just can't read the abstract results which many physicians have a tendency sometimes to do. And so all they see is this study came out and look, it says there's no difference between 33 and 37. But you have to look at the fine print, you have to look at the sample population that was served. You have to look at the characteristics of the patients entered into that study. You have to understand the EMS system where the studies are being done because there are vast differences. If your patient matches the population of that particular study that was randomized, then by all means, follow the guidelines. But I think there's a little bit more to target a temperature management than choosing one temperature. And it really is all about individualizing the care of your patient to their specific physiological needs. And that is the message I want to take. I want you to take home. So our subject of interest is post cardiac arrest syndrome. So we have a patient that's had a cardiac arrest. The uh patient has had uh hopefully CPR maybe no CPR but they get a return of spontaneous circulation. So back in 2008, Nolan at all, uh published a definition of post cardiac arrest syndrome as unique and complex combination of path of physiological processes with four key components, systemic ischemia reperfusion, meaning there was no flow or limited flow. And now we have reestablished flow back into that area of the body. Myocardial function could be the precipitating event, hypoxic brain injury. The brain gets just as hurt as the heart. And if there's one message I could send a cardiologist, it would be, it's not just about the heart. Ok. I can transplant the heart. I can't transplant the brain. The when the brains hurt that there's not all we can do is try to minimize the damage, restore normalcy to the brain and then the underlying cause of the cardiac arrest. So, ischemic uh systemic ischemic reperfusion injury may be reversible and responsive to early goal directed therapy. What does that mean? It means that if you act fast enough and you institute therapies to preserve or minimize that chain of reaction, that's gonna happen it's like a domino that starts, you kick the domino and the effects that you see. Well, there's some early effects but there's also some late effects. So injury to the entire body is activated, uh causing cascades. So, think of your dominoes which disrupt major systems. There's cytokine disruption, there's release of endotoxin, there's leukocyte activation, you have coagulation activated, but it's not uh balanced by fibrinolysis and it activates the vascular endothelial on the system. Leading to vasoplegia. The clinical manifestations of that physiologic process are hypotension, ongoing tissue, hypoxia, cardiovascular clogs collapse, pyrexia or fever, multisystem organ failure and infection. So think of the hit model that the brain and the body take. So it's actually a two hit model. You have that period of hypoxia noia, you have a rise in changes and there's chemical and and there's all these processes that have happened because of the lack of oxygen and blood flow. And then it's not just in that first minute or that first hour, the cascade continues. It's like if you have an infinite domino to thread that goes for days to weeks after that insult. So it's not something we're just immediately going to see. We're going to see the effect of that for several days after the event. There are studies that have shown door to targeted temperature management initiation impacts patient outcomes. So there was AAA great study by Mike Mooney. Uh Let's see if this works. If I do this No, let me see. There it is. Ok. So if you looked at this is from 2011 and I actually had the honor of sharing the stage with Mike Mooney. And uh a number of years ago, he's a cardi interventional cardiologist at Abbott Northwestern in uh Minnesota. And he looked at the data for uh both initiating TT M as well as getting into the cardiac Cath lab to be able to find whatever was going on. And there was a 63% less chance of survival to discharge if uh there was a delay in instituting TT M. So initiation of TT M had to occur within 100 and 22 minutes of hospital admission and every hour you delay would decrease. So recovery increases or you can look at it, look at it in terms of the mortality would jump 20% for every 60 minutes you delayed. So it's not OK to have them go to the calf lab first and then come up to your unit and then start TT M. That is not OK. You need to start TT M in the emergency department or in wherever you are with that patient, it needs to be started as soon as possible. So there was also a multi center postdoc analysis of 570 post arrests patients. There was variability in initiating TT M. Most patients had TT M started by hours 3 to 4, survival was much greater if cooling started within the first two hours. So you can see that graph on the mortality or uh survival. Now, immediate stabilization. So, what are you doing in those first minutes after you got? Oh, there's a pulse. Ok, great. Do we have a blood pressure? What's our oxygenation like? So, in those early minutes after restoration of circulation, we're looking at ways optimizing oxygenation, optimizing perfusion to the brain, right? Controlling body temperature usually come in cold and it depends where you live, right? If you live in Minnesota, you know, they may, and it was outside, they may be very cold. Um There was a period we had in uh California where people were going out in the middle of the night and it was a real cold. I mean, for California, 40 degrees is cold. Ok. So they would go out in the middle of the night to let their dog go to the bathroom or feed their dog and they topple over. And I was like, you know, that's just a bad idea. Don't get up in the middle of the night and they'd find them and their temperature is like 87 degrees and they'd be really cold when they came in. So you got, you gotta know what your patient's temperature is and then you have to uh make a decision about what, how you're going to mitigate that injury. So what are the current professional recommendations for immediate post cardiac rest care? Well, there are a number of documents I'm gonna run through including the 2020 full A a guidelines and that 2020 guideline document it recommended. Um If you, if you follow the algorithms with AC LS, it recommended ins you know, airway breathing circulation, you gotta, you know, work up the patient for a semi, you know, think about calf lab 12 lead. But then if you get down into the bottom ba uh box, you can see in comatose patients following the turn of spontaneous circulation. TT M is right there on the top. Now, there also has been a uh update to the guidelines and they are encourage you to look at this patient in terms of the chain of survival to include recovery. So it's not just OK to think about. Well, did he have a left ad anterior descending artery or a left maine? And I'm not I my cardiac is like 40 years old, although I am an A CS instructor, but you know what I mean? If there's a big vessel, yeah, we got to get that open, but we also have to pay attention to establishing a means to mitigate the injury to the brain. There is a 2024 A H A focused update on AC LS support. It has specific information following the TT M two guideline or study that was published in 2021 by Danko it at all. So it says we recommend all adults who do not follow commands after spontaneous return a spontaneous circulation, irrespective of arrest location or presenting rhythm to receive treatment. That includes li strategy for temperature management. So even I I know there are a few hands that says they don't do it. Well, you should pay attention to temperature and you need to avoid fever. And there is a quote there that specifically states, you know, I'm not going to read all of it to you. But what they're basically getting at is that there are a number of trials and the A H A did not um fully align with Ior, which is like the European group that establishes their guidelines. And the, the A H A said, choose a temperature for target temperature manager between 32 and 37. That was their recommendation, but it must be based on the characteristics of that individual patient's arrest. And so what I'm going to tell you is that you need to consider multiple factors when the team is making a decision about TT M. So when you look at TT M, the recommendations, selective temperature between 32 and 37 the hospital must develop protocols for post cardiac arrest care and temperature management. It needs to be maintained for at least 24 hours after achieving the target temperature and you must actively prevent fever. The brain does not, I like to be hot, it increases uh uh oxygenation demands, it increases cerebral blood flow it worsens cerebral edema and it increases intercranial pressure. The brain does not like to be hot. What's not recommended is patients with spontaneous hypothermia. After ross unresponsive to verbal commands should not routinely be actively or passively rewarmed faster than 0.5 degrees. So anytime we have even an incidental hypothermia patient, we will re we'll put the pads on them and rewarm them up uh very slowly because of the shifting of electrolytes. There's insufficient evidence to recommend a specific therapeutic temperature target for different subjects. So the A H A and the N CS uh C uh came together, I was the current president of the Neuro Critical Care Society at the time when this initiative was launched and I was a member of that panel. And what we did is we reviewed 100 and 77 sources evidence we had different categories. It was a multidisciplinary group. Uh Doctor Sarah Livesey was one of the members. She and I did the one section on bundles of care and uh family considerations and neuro assessment for nurses. We did that particular section. But um I encourage you to take a look at this document that came out in November of 2023 in both circulation and neuro critical care. And what that guideline document has are a number of recommendations based on a review of the literature and consensus for managing every organ system. Now, it does not have tt M recommendations because the was working on that 2023 2024 depends when you downloaded it, that document and they said, you know, wait, why just leave that out? And so we addressed every other system. It's really too much to um go over and take a whole session to uh review and to talk about it. But it literally, it addresses the neurologic system and it had psy experts from around the world. Uh Jerry Nolan sat on it cliff Calloway from Pittsburgh sat on it. Um I mean, the leaders like the who's who in post resuscitation care? Uh Kate Berg, who's uh one of the leads on the uh 2020 AC LS group. So these were experts, Romer Gak and I mean to name a few people, but there are recommendations for management, seizure management, pulmonary management, cardiac semi management. There's recommendations on renal, like how you manage your kidneys, how you manage glucose and electrolytes. And then how do we put it all together, which is bundling care in a means that easy for um uh nurses at the bedside and teams at the bedside to implement. So um please take a look at those guidelines. Lastly, there's a joint commission resuscitation requirement document. I don't know how many of you saw this. It was called the R three report. It was published in July of 2021. So our hospital, I'm the chair of the resuscitation or co-chair of the resuscitation Committee. And so I um knowing that what the work I'd done with the A Han CS group, which was a two year journey. I came to our uh executive Director of Cardiovascular Services, our chief nursing officer, our intensivist team, our emergency department and cardiology team, our neuro team. I said, look, we need to come together as a multidisciplinary team. We need to do a review of the literature. So we just didn't review like a study and I couldn't even share the 2023 publication because it was 2022. So I knew what was in those guidelines. But what I did, I was, I, I asked if I could share the references. And so we had, we reviewed 100 and 77 sources of evidence in these different topic areas. I had a physician and a nurse leader, either director, manager, clinical nurse specialist, or nurse practitioner and we had staff nurses. So I had 28 staff nurses from the emergency department, from the critical care unit, the cardiovascular, the neuro IC U from uh uh uh our rapid response team and each nurse reviewed six articles, did an evidence-based review and they presented it in small teams, the teams made decisions on what they're going to recommend and to put in that guideline document. Because what the joint commission is asking for is you need to prove or show a comprehensive multidisciplinary post cardiac arrest protocol and how you manage comatose patients. You must have that document. It also specifies, you must collect data on your, on your arrests and on your outcomes. And I don't know if it institution you have that. I do 100% review of all in hospital cardiac arrests. I also do 100% review on our, our uh we have a method, our pads allow us our, our CPR pads allow us to look at compressions. You have to report compression quality and you have to report your outcomes and your failure to rescue in codes outside the IC U. So we took and created a document that contains 100 and 77 resources and evidence and built our uh we agreed on what our TT MS is going to be. We uh agreed about, you know, I had, we actually viewed extra articles on TT M. So we went a little outside of what the A Han CS did. And so we established uh or reestablished our, our protocol. So we have that and we've been collecting, I've been collecting data on post cardiac arrest since 2000. So I can tell you from 2000 to 2024 what our survival is. I can tell you. Uh I mean, I can't tell you off the top of my head for everything. But um we also review 100% of our TT M cases and it looks at what the target was. What's their outcome? What was the adherence? How fast did we get it to 233 or 37 whatever we chose. So I want to start with uh two cases. Case number one, a 63 year old male is sleeping when his wife heard snoring respirations and went to find a BP cup. Now me, when my husband snores, I do this. You're snoring. Get off your back. That's my. So now after I read this case, I was like, oh jeez, I guess I should check them out. Anyway, she comes back into the bedroom, checks a pulse and started CPR because he was did not have a pulse. Uh She called 911 patient was in a ventricular fibrillation arrest paramedics arrived. CPR was done times 20 minutes. Now you might see some bold epi times five. OK. So these are some key elements of the arrest patient was uh uh uh had uh amiodarone atropine. Uh Ros was achieved after 20 minutes. The Glasgow coma score post arrest was 111, he was intubated in the emergency department. His NP I and the pupillometer we use as part of our new assessment, a pupillometer device. I don't know how many of you caught doctor Dawa Olson's talk yesterday or we talked about it on Monday at our session. But um it's a device that quantifies pupil reactivity. How many use the pupillometer in clinical practice? If you don't use it, you should because they're the subjective assessment and the reason I'm going to tell you this, you're not that good. I'm not that good. Using a flashlight, your assessment. 50% of the time when doctors neurosurgeons, neurologists, nurses say that the pupils are reactive or not reactive, they're wrong. And so when you look at the studies that compare human assessment of pupils to that device, the device wins every time it's a quantifiable number and NP I is between zero and five, anything above three is normal, anything under three is abnormal. And if there's a difference of 0.7 that is abnormal also. So this uh the NPIS post arrests were 2.9 and 2.4. So they're abnormal, they're abnormal because he's had a significant period of hypoxia or noxa from the cardiac arrest. Uh He also had a 12 lead EKG which you can see there with deep ST depression in V one to V six and ST elevation in uh lead one and a bl. So he's obviously a stemi right now, we look at his blood pressure and hemodynamic support. He's on norepinephrine. OK. 3.5 mics per minute. So I do that right. All right. So case two, it's on this computer. It's really teeny I have to look at here. So a 62 year old male was walking with his spouse when she heard a fall. I don't know if he was walking, she was walking in front of him, but she heard him fall. CPR was initiated immediately. 911 was called EMS arrived five minutes of of CPR monitors showed uh VFIB they gave one shot. Had we turn a spontaneous circulation. The patients in sinus tachycardia at the scene, the Glasgow coma score and admission is 241. So seven intubated. He's not following commands. So this is somebody who's reclassifies comatose his NPIS and his pupillometer are four and 4.2. So they're better, right? OK. 12 lead EKG shows ST elevations in lead 23 and A BF concerning for an inferior wall M I blood pressure is good. He's on no drips are those two arrests different. Yes, just the characteristics of those. So how, what info do we need to gather and share when we're looking at post arrest patients? Can the patient follow commands? If they can follow commands? They don't need, you know, they don't, they're not going to need the intensity of care that someone that's not following commands. Do we uh know the cau the cause of arrest? What vitals are important? Stability, what support are, what hemodynamic support indicative of cardiopulmonary failure? What's the current body temperature? Do you have a decision tree at your hospital? And how do you rule out bias in your assessment? So these are the bundles of care that appear. Uh Well, our bundles of care are based on the major categories in the 2023 circulation article, but we have gone further in that we have defined interventions and goals. And this is a product of that 2022 2 month evidence-based project that we ran. So I ran that project in two months. I am not someone that's going to run a project for a year. I believe you get the literature, you review it, you come to consensus and you put together a protocol. I am not for dragging my feet for six months where people forget. So oxygenation ventilation, you can see the interventions GC S3 to 8, you're going to get intubated, right. You're gonna get blood gasses, cardiac and hemodynamic optimization. They're going to assess heart rate and blood pressure and EKG if you're hypotensive, you're gonna get uh support, you're gonna get fluids, consults, pulmonary critical care needs to be at the table cardiology with the ed doc and neurology and neuro critical care need to be there. They're part of this team taking care of the patient, me metabolic derangements. So, glycemic control, you got to look at your electrolytes, you got to look at your EBGS TT M. Where are you going to go with this patient? And you should be beginning tt M. The decision is made to proceed in the emergency department which needs, you need to bring the IC U to the er number one early cardiac intervention. You know, if they have an occluded vessel, they do need to get to the calf lab and rapidly, but you can't forget to do your ABC S in the process, neurologic care. So we do our neuro exam, our pupillometer assessment and we have a rapid response eeg tool. It's a headband eeg that's put on within 30 minutes of ros and comatose patients. And then family and caregiver support is also an integral part of that. Now, this is the bundle for critical care. So that first was the 1st 120 minutes. This is the uh bundle elements of the next you know, critical care phase. Again, you see this similar oxygenation ventilation, cardiac and hemodynamic optimization. TT M instant rearm, cardiac work up, neurologic care, seizure, surveillance metabolic arrangements, neurop prognostication, which should not even start for 72 hours, post arrest. So they shouldn't be prognosticating on day one and then family and caregiver support with shared decision making. So is it safe and effective to call? Would you say that the study shown it's safe and effective? Yeah. So um we're gonna go through a number of studies. So the RCTS for class one, this is highest level of evidence. There are four major studies that a lot of people refer to the Bernard and Hacker study of of 2002. This these were the landmark studies that uh shepherded in the the era of TT M management where they saw significant improvement in patients who were cool before machines existed. They were cold with ice bags and and and wet sheets and all sorts of things back then, uh and then they had significant poo, you know, people that just had, well, whatever their temperature was, Nielsen uh is part of two European studies, the 2013 TT M one study and Danks and Nielsen at all. And the TT M 2021 which looked at 37 versus 33 and saw both of those studies saw no difference in outcomes between the two targeted temperature managements. So what's interesting is the Bernard study very controlled randomized. Uh and they looked at those two groups of no TT M versus TT M to 33 whereas Nielsen did 3336 and then 33 to 37. But when I said, you need to look at the fine print, you need to look at the fine print. First off, this was done in the majority in European centers, their EMS system, they have a physician typically on their EMS crews that goes to the scene, they stay in play. What do we do in the United States? We load and go right. Ems goes, they start CPR, they get them in the ambulance and they're doing CPR in the ambulance or they have the device that's uh A as they're, you know, coming into the emergency department. So, so there's a difference in EMS systems. A lot of those cases, the really bad cases, my guesses are called in the field and they don't, they don't transport with CPR in progress, the other thing you have to look at is their inclusion criteria. So if you look at their inclusion criteria, bystander Witness CPR 91% these are two groups. So 33 and 3037 bystander perform CPR 80% average in your geographic region. Can you say there's 80% immediate bystander CPR? No. In in our case, we looked at our date, it's like 34 35%. Uh Seattle, I think has some of the best, maybe Denver. But typically we don't have, usually those patients don't have immediate CPR. So there's a longer period of no flow that our patients may have versus these patients, right? OK. The, the rhythm you look at VTAV FB or so VFIB, it was 62% of their population, uh V tac or uh non, let me say non perfusing ventricular tachycardia. And then you look at Ross and then the last thing I want you to focus on is bilateral pupillary in uh response, 70% of their patients had pupils intact. Ok. So from a, from my vantage point as a as a neuro person, that's a pretty good patient population, you know, because pupils, you see a lot of people come in with non reactive pupils and then if you look at the curve, there was no difference in their outcomes of that study. Well, one size fit all and I'm going to argue the facts. No. So hospitals that have looked to switch So when TT M one came out, I know Harbor View in Seattle or University of Washington. Harbor View switched to 36. Bray. I, uh, is a, uh, a physician in Australia. They went from 33 to 36 when they took a look at their data. Several years later, they found an increase in mortality and poor neurological outcome from the patients. They've been cooling to 33 when they went all in at 36 and those institutions went back to 33. Why? Why is that important? Do you collect your data? Do you look at your outcomes? Do you even know what, what your patient's neurological outcomes are? If they got TT M or they didn't get TT M, you need to take a hard look at it. How do I match and choose the duration, the temperature target? What about severity scoring? So there are a number of articles published that looked at uh severity scoring in choosing the appropriate temperature. So Calloway from the University of Pittsburgh at the Peter Safar Institute of resuscitation, published an article in 2020 where they had a wrist stratification, PC AC A PC AC of one is normal like you're awake, you're talking a PC AC of two. These are patients that um got 36 degree or that they were um I don't have the exact thing in here because um there was not room for it, but basically it was uh patients who had short uh arrest times, they didn't have any cardio fear, they're not on any drips. They had a very short like five minutes, 10 minutes. CPR mainly V fib uh pupils reactive. So not as neurologically sick and for those patients, they did better at 36 than 33. But if you look at the PC AC three and the PC AC four, which is loss of some brain stem reflexes, which is pupils, you look at long cpr times, epinephrine given multiple times during the arrest, norepinephrine drips in support. So what they call moderate or severe cardiopulmonary failure, those patients did better at 33 than 36. Now, Nish Akimi attempted the same thing. He used a different severity scoring and um it was a number of metabolic factors. And so when they took a look at well, what patient populations benefited. If you looked at the curve in their publication, it showed that the patients that did best at 3334 were those patients who had an R cast severity score much higher. If you had a mild one, you did better at 33. So you're starting to appreciate that there may be differences in how I should choose my target nut A at all. 2022. This was an eeg study. Good outcome C PC 1 to 2 in patients with moderate encephalopathy was significantly larger after TT M at 33 than 36. So let's look at the brain. What's the brain outcome in these patients? So that led me to because I started to get uh emails or texts from our Pulmonary Critical Care Docs. There's like eight of them. And they'd say, I don't think we need to do tt M anymore. And I said, oh, wait a minute. So I had the honor of reviewing about 25 studies. I looked at risk stratification and we developed uh this and I presented this to our Critical Care committee. So on the one side, you see the exam, you see PC AC 1234. And so what I did is I took the criteria that were uh from Pittsburgh. I had to modify one criteria. They use the four score motor score in their uh Pittsburgh. But our homemade critical care guide don't even know what the four score is. So I chose the motor score from the glas glaucoma score to replace that. But it has to do with, are your pupils reactive? Are your MP is four or better? Um Did you have a five minute or 10 minute cardiac arrest? Did they give like one ee one shock? Uh Was it a, you know, so looking at those kinds of things, we um categorized to PC AC two and you can see that 37 or would be the, you know, target for those patients versus the PC AC group of three and four, which stratifies the NPIS in the pupillometer, the gla glaucoma motor score is a little lower. The arrest times are longer. They get 33. So 75% of our patients are called to 33 about 25% of our patients are called to 37 or maintained at 37. So when I tell you, this is the excuse me, the algorithm that I developed, that asked the physician and the team to take a look at all the qualifiers for uh the, the ch choosing your temperature management. And then the, the lead intends as the director goes. Can you put it on a card like this big? I'm like you are literally kidding me. Um And after about eight hours of the NAG, I finally got it on, you know, one side has the one thing and the other side has the algorithm and I'm happy to share this with you, but this is based on a number of articles like 25 different articles and so one size does not fit all. So in our cases, we have case one, the VFIB patient with a long arrest who's got some mild cardiopulmonary failure. He's on norepinephrine. What temperature would you choose for that patient? How many would choose? 37? How many would choose? 33? Ah Now case number two, the V fib immediate CPR five minutes, Ross. No ep uh no, no Epinephrine support. Uh pupils are four and 4.2 on the MP I how many would pick 33 for this patient. How many would pick 37? Yeah. So you see how it can help you understand the characteristics of the arrest. So if you choose to lower temperature and uh to down to 33 degrees know that there are a number of phases. So there's an induction phase, a maintenance phase, a rearm phase and then normal therm with active fever, uh prevention and these phases of temperature control need to be done right at my institution. Not every critical care nurse may take care of a post cardiac arrest patient undergoing TT M. They have to have a specific competency isn't the AC N model of matching the nurse's skill set and knowledge level with the severity of insult and the patient needs. You can't assign any nurse to take care, do TT M if they have limited critical care experience. So our nurses every two years attend a five hour post cardiac arrest course. I teach them, we go through studies, we talk about every system management. It's not just about TT M. We talk about every system, we talk about goals, we have reference sheets for them at the bedside. Uh It, it we struggled a bit when we joined Providence uh a few years ago and they switched us from MEDITECH to Epic and MEDITECH, we had complete control of our order set. So every order set in our institution matched our protocols. We went to Providence let me tell you, it really threw a cog in the wheel. Uh It like upset the Apple cart repeatedly. We can't design our own order set. We are very frustrated. They've just redesigned it. And uh you know, my colleague, uh Teresa Waver, who's the cardiovascular clinical nurse specialist, who really does a lot of the work. I mean, I wrote the first protocol but she's, we work on it together. Um She is so, you know, we're so frustrated because the docs are like, I don't have the orders. I need, the nurses say I don't have the orders I need. So we have streamlined, our order sets a little bit and order did some order panels. But that's really important is to have that order set that matches. So these are our protocol bundles for induction of targeted temperature management. How it relates to oxygenation, ventilation, medications, hemodynamics, cardiac catheterization, neuro seizure management and metabolism. When you induce hypothermia. First off, you got to have a temperature probe some source in the body so that it provides a feedback loop to whatever machine you're using. You know, uh it doesn't matter to me what machine you use. It just make sure it works, make sure it doesn't have any fluctuations and that there's this feedback loop so that you can maintain good control over the temperature. When you induce the patients who are already intubated, you need to start sedation, you need to start your propofol, you need to start some fentaNYL. And at our institution, we will deliver a bolus of a paralytic when we start because we don't want them shivering when they go from 3536 down to 33. So, what we do is we give them that paralytic and that usually kind of helps their journey. And it also makes it faster because if you don't do that and they're shivering that's gonna counter your work, the work of the machine. So, um uh we do deliver that paralytic, just it's just the bolus. And then, um we continually assess their vital signs and neuro checks every 30 minutes till they get to their goal temperature. And we do the bedside shivering assessment score on a routine basis during induction to make sure they don't start shivering. And then we institute antis shivering protocol. So the goal with induction is get down as fast as you can to 33 or your target temp, maybe it's 36 maybe it's 35 whatever your docs are picking. Now, TT M at 24 hours, the 10 priorities are maintained this steady state. To me, this is the most stable time during TT M. They're usually, they're not vasoconstricted. Their blood pressure is better. Their heart rate slows down the normal heart rate when you are, uh at 33 is about 34 to 38. It's like, you know, a bear that hibernates in the wood. You ever check the pulse of the Bear. When I, I don't think that's a good idea. There's never been a randomized study to check Bear's pulse, but we do know when they hibernate. Right, their body temperature goes down and their heart rate goes down. The conduction system slows. So you got to measure your QT interval when they're cold, you know, make sure there's no arrhythmias that are happening and typically they're pretty happy with their heart rate at about, you know, 38. I don't really get all that wigged out about it. Um And then we're going to continue to assess for shivering as shivering reemerges. You're gonna have to address it. There's um every time you do tt M you should have a sh antis shivering protocol. Like you start bear around the clock, you might need to up the magnesium levels to 2 to 2.5. You may need to, you know, give a little Demerol, a bear hugger or a warming forced air thing works miracles. You can have people with goose bumps, put it on and then it, you know, kind of takes the goose bumps away. So there's lots of minimal invasive things that you can do and then like the bear potentiates the meperidine. So when you give a meperidine bolus at 25 you know, it can help it work a little better and then you kind of gradually go up fentaNYL, uh increasing your propofol, et cetera. I do not recommend using dex meat toid at 33 because when your heart patients, heart rates 38 it'll end up being 22 and that's not too good because decks actually will uh cause hypertension. It causes some sig significant bradycardia. Now, in uh the rewarm is the most dangerous time. And during rewarm, we're coming back up to our target of 37 degrees, it needs to be slow and steady. So we typically choose the default is 0.25 degrees an hour. Why is that? Because when you induce hypothermia, when you go down, the, the potassium is driven into the cell. So when you're cold, you have lower than normal potassium levels and you're kind of trying to manage a potassium level that you know, when you rewarm is gonna go significantly up. So there's a shifting of electrolytes that happens. Sodium goes out of the cell. Potassium goes in the cell when you're cold during induction. So you'll see the, the K go down to like 3.23 0.3. Don't overcorrect that where they're at target. Because what happens when you rewarm is those electrolytes shift back out. And if you start with a K of 4.5 you're going to end up at six when you get back to your target temperature, especially if you're at 33. So there's a lot of stuff that's changing. The, the electrolytes are shifting seizures if they are good occur in the postcard comatose, post cardiac arrest patient uh manifest themselves more often during the rewarming phase of TT M. So you're, you're watching out for seizures, the blood pressure will lower because you, you vasoconstricted when you're cold. You know what that's like you get cold ivory nodes disease. And then I tell you if I drink a 32 ounce bottle of ice water, my hands are white and we can testify to that because they've seen me at lunch. They go, oh my God. Look at your hands. Well, you know, you shunt, you, you, you vasoconstrict when you're cold and then you vasodilate when you're warm and as you're warming, then that blood pressure is going to drop. So those are some of the really important things you're watching for shivering because you're going through the shivering zone, intracranial pressure and cerebral edema are going to occur during this rearming phase. There have been times when we've had an MP I in our pupillometer and during rewarm, we lost it. And so then we held at that temperature for 1224 hours and then we restart it. And that's just based on watching, you know, changes that are happening up here to direct what we're doing. And that's a decision that we've made um to see if we can uh like help the the brain along a little bit. Last thing is blood sugars, watch your blood sugars because when you're cold, you're insulin resistant, right? You have you ever done an insulin drip where you're, you know, you start, uh, it's a diabetic patient type two and you're at four and then you're at eight and then you're at 16 and then you're at 20 units and you can't get the blood glucose down. Why is that? Because it insulin resistant when they're cold. But as you rewarm, guess what happens, you get hypoglycemic because, um, the insulin that's been, you know, cruising around is uh acting. And so you can see periods of hypoglycemia, especially if they're on a concurrent insulin drip. So you got to be very careful with your glycemic control. So case one and case two, how are they say the same and how are they different? So you all guessed you all chose correctly TT M to 33 degrees was chosen for case one times 24 hours and then he was rewarmed. He did go to the Cath lab on the day of a mission. He had a left circumflex already. That was 90% occluded treated with a drug alluding stent. And then case number two, he was the TT M target was chose as 36 by the pulmonary critical care doc. He went to the calf, he had 100% occlusion of the right uh right coronary artery, 90% stenosis of left anterior descending. He was treated with a staged approach. He got on the day of admission drug eluting stent. And then on this uh a few days later, they were day 10, I think he got a drug alluding stent stent to the left anterior descending artery. So he was uh managed at uh uh sort of a normal therm at 36 kind of thing. Uh and then rewarmed to 37 and fever avoidance times 72 hours. So our, our don't forget there's a neuro, there's a brain and you need to assess your patient's uh neurologic function and how you manage cerebral edema. So a really good neuro assessment uh level if if you, if you're able to, I encourage you to listen to the talk that doctor Dawa Olson and doctor Sarah Livesey and I did on Monday on elevating your neuro assessment kind of go through all the major elements of a neuro assessment. So uh brush up on your neuro assessment, look at your pupillometer data. Uh and then also uh make sure that you, you know, have had a bed at 30 degrees in these patients and that you're treating any um evidence of cerebral edema or seizures. So, seizure, these patients need eeg monitoring. Continuing. We typically do continuous eg mining for up to 72 hours. And believe me, we're a community hospital. We don't have EEG techs 24 hours a day. So our rapid response head bend eg is applied and then as soon as the EEG tech comes in, they work from 8 to 6 as soon as they come in then we um f flip them over to full montage eeg, we do it for 72 hours. The neurologist, epileptologist can choose to monitor the eeg longer and you can see changes in the eeg. Um some patients it can look really bad, but you can see a background rhythm come up by 24 hours and you see changes at day two and changes at day three or sometimes you see it get worse, right? As they progress to brain death. So, um having that eeg monitoring is key neurop prognostication should not take place for 72 hours after RSP. Now, I understand when the 99 year old who's demented, who lives in a nursing home or skilled nursing facility and has an arrest and arrives at your hospital because the family wants everything done, right? But they come in and they've had a long arrest, you know, they're the, the, the team's gonna look at that, talk to the family and just probably recommend, you know, no tt M that they're not really, there's no meaningful recovery that can come. So some decisions are made in the emergency department, but you, you can't in somebody that is, you know, has a meaningful existence prior to uh that arrest. Uh you know, you shouldn't like say, well, he's a goner and, you know, don't do anything. Uh So it is important in comatose patients uh following cardiac arrest that we wait 72 hours and that you have a multimodal neurop prognostication part in your protocol. And that is part of the Joint Commission guidelines from 2022 that went active January 1. It says your protocol needs to have a section that says elements of neurop prognostication are important. What are you going to use as your? So we send neurons specific analyse, we send lab tests uh every day for three days. Um They get imaging, the clinical exam by far is the most important and there's um sse pe eg uh so biomarkers, imaging, all those things need to be included. So uh sudden cardiac arrest that if you look at a national public health crisis, I I do believe it exists. Cardiac arrest is the third leading cause of death. It strikes all ages, it affects 1000 people a day and functional recovery continues. It's just, it's like severe traumatic brain injury. What that patient looks like at day seven is going to be very different at three months, six months in a year, there is continual improvement in in many patients, not just what you see at three days or seven days. So it is a continuum and um you know, supporting the patient through this continuum. If you really look at the A OS guidelines, they have a whole section now on post uh arrest recovery and how important psychosocial support is assessing depression. Uh uh educating the caregivers who are going to be with them ongoing neurologic therapy, OTPT speech. That's all part of AC LS. Now. I know we kind of ignore it and think I just need to pass the or whatever. How many of you do that every three months you get questions for your AC L si mean, we do that at Providence and I have to laugh. I mean, I've been an AC LS instructor for 42 years. Ok, a long time. Those multiple choice questions are stupid because I've actually scored like 70%. It's like we don't do that. I, I developed a stroke protocol and I, and I mess up the stroke questions every time because we do everything in five minutes because we're in the CT in 10 minutes. And they're like, oh, don't do things for 15 minutes. I'm like you are not right. But anyway, um keep up your AC LS and your BLS. That's, that's really important. So, um when we look at 2023 med meta analysis using the older Hyper on trial, I don't know if how many of you read the Hyper on trial. It was out of France and it looked at TT M and a Sicilian pe a arrest. And when they published their study, they've had um C PC as a scale you used as an outcome uh cerebral performance ca uh uh category. It's, it looks at their brain performance in their recovery and when they did TT M to 33 versus 37 in non shock rhythms. They had a 16.4% good outcome defined as C PC 1 to 2 versus 5.8%. They just got no uh targeted normal theia. So there was a significant difference. Now, Taone, I know Fabio Taccone, he's out of Belgium, he was on the AJ uh N CS panel and he, you know, lives in the world with dank and those guys from Europe. And so they've had this publication which is a meta analysis of TT M two and Hyper on. And what was interesting to me is when they looked at, when they looked at it. So that was blank study. But this uh that's in hospital. I'm sorry, confuse it to Lara study, which is the hyper run study showed 10.2% C PC 1 to 2 versus 5.7%. 37. I got a little ahead of myself to coni study what they did is they just looked at CBC one and they said, oh, look 6.5% at 33 and 5.6% at 37. There's no difference. And I'm like, wait a minute, the study that was published had C PC one and two as optimized neurological recovery and there was a difference. So I kind of miffed it fabio for, for doing it the way he did it. And, and I, he and I um shared the podium before and we argue about it all the time, but it's ok. He has opinion, I opinion. So, uh Cochrane review did a uh review of TT M to 3234 which was published in 2023. And you look back through previous studies and uh found that, you know, adults called by any method within six hours. They reviewed 12 randomized controlled trials and quasi randomized controlled trials and patients called in the therapeutic hypothermia group more likely um to reach their uh good neurological outcome. And so good neurological outcome is this is recommended in the Cochrane review. But they looked at, you know, does um cooling to 32 to 34 improve outcomes or help uh Germany and Austria. So I was over in Germany in January speaking at the A a meeting which is the German neuro critical care meeting and both German and Austria broke, broke from the uh A L core guidelines and they do 32 to 34 for their TT M target. So that it was very interesting to see, you know, they looked at the day, they don't agree with it. So they said no, there's more evidence for 32 to 34. Um There is current active research on TT M from the siren network and this is the uh ice cap study. So there's a study in adults and there's a study in pediatrics that's going on. They're currently enrolling patients and it's looking at the influence of cooling duration on efficacy in cardiac arrest patients. So it's a multi center randomized adaptive allocation clinical trial to identify optimal duration of induced hypothermia for neuroprotection and como of survivor of cardiac arrest. So, they're looking at 24 the one of the criteria is you got to get down within like four hours to target temperature and it's looking at 24 hours, 48 hours. So that's that these two studies are in progress and uh I am hopeful that, you know, it's going to give us some more data to make our decisions. So in summary, the outcomes of our two patients case number 1, 63 year old male with prolonged CPR times 20 minutes, his hospital length of stay was 40 days. He was discharged home with home health neurologic status. The patient was alert and oriented with the G CS of 465 and he was at baseline from his pre uh prior to arrest level. So he was basically went home pretty much intact. The 62 year old male with CPR times five minutes. His hospital length of stay was 13 days. He went to rehab. He was in a ru for a couple of weeks, his neurologic status, uh discharge G CS 465. He was still working with PT on mobility. So he was doing outpatient PT, he was using a walker, he was working with PT on ambulating and stair training and OT he he was impulsive and highly distractible. He responded well to cues, but he was working on his AD LS. So, not quite the same neurological outcome as um case number one. but, you know, had a pretty good outcome. Don't forget your performance metrics. I challenge you to go back to your institutions and ask the question. Do we collect data on our cardiac arrest? There's some, there's a registry that the American Heart Association has. Um it uses Osteen's criteria that was recently published in 2019. And if you don't have the reference, I can, it's in my references, but I can give it to you. Osteen's criteria is uh in hos or it's a out of hospital cardiac arrest that survived to in hospitalization and it has characteristics they also have in hospitals registries. So we have that data. It's, it's, there's probably 100 points of data that I collect and I dig into the chart and you need to have that information and you need to review it. So I deep dive every single arrest that happens outside of IC U or er OK, every arrest I it's called failure to rescue. What did we miss on the floor? That patient, if they're on the floor, they should not be arresting. What I have seen in the last six months is a huge increase. We averaged three, a quarter of out of IC U arrests. We are the last couple. It's like been 11 and I'm like, what in the name is going on? Most of them, two thirds of them are happening at night. What do you think has happened? We're collecting uh about 40 different pieces of information on every one of those cases from when they came into the, er, who was the charge nurse? What was the ratio, who was the patient's nurse? Uh through the, er, to the floor? Now they're on the floor. Who's the charge nurse? What's the patient load on the unit? How many admissions they get that shift? How experienced was that nurse? And the other concrete data? How about your institution? How many new grads you have? Where are your new, what shift are your new grads working? Uh huh. Uh, so take a look at your, you might be surprised we had, um, we're doing this deep dive getting into the nitty gritty on every single out of IC U arrest. And, um, it's not just in the, out of IC U, we actually went and looked at how many arrests occurred days and nights. It's one of the things I collect in the data and most of the critical care arrests are happening at night. So something's going on and we got to figure it out whether it's, people aren't recognizing the de deterioration and the arrest happens because they didn't pick up on it or maybe they have four admissions at the same time and they were really busy you know, we don't yet know the conclusion. The joint commission asks you to collect this data and show the report when they come the number and location of cardiac arrests transfer at a higher level of care timeline, timeliness of staff's response, cardiac arrest rate and quality of CPR, you have to report compression quality. So we get that from our, our, our monitor device whi which shows us compression, depth compression rate, all that kind of stuff, outcomes of resuscitation. So return a spontaneous survival and survival to return of spontaneous circulation and survival of discharge, review, arrest and non uh monitored or noncritical care units. Your institution should be reviewing every single out of the IC U arrest. Do you do that and then post cardiac arrest care process and outcomes following the cardiac arrest. I'm happy to share the database that I put I built in Excel. Uh It, it's a basis of how I could take my data together and then present that to we meet in our recess consultation committee quarterly and I report that dated our critical care committee and we often send Q uh uh cases to QR C our physician peer review. And we said, you know what that nurse, that floor nurse called the doctor four times over the course of 12 hours and the response didn't meet that patient's needs and that patient arrested on the floor. That's not OK. So we send that off for peer review. So actionable items that you need to take, update your post cardiac arrest protocols to reflect the 24 2024 guidelines. Um Gather the team to reflect multidisciplinary specialty input, speak up and advocate for patients, survivors of cardiac arrest schedule education and training. You need to have some kind of course, I can't believe that places just expect nurses to go and, and, and do this and it's very complicated. So have some type of competency based learning and competency skills criteria that they can check off so that they can then take care of these patients, collect data, implement uh quality improvement. Um uh Take a look at some case studies there. They're very powerful and seek support from trusted professionals. So that's sort of my ask of you as you go on your journey to go back home. Uh There is information that can be requested from BD. Uh And they uh also ask your feed, your feedback, my email once again, bader MK at aol.com. And there's an email for the MS L team at BD TT M MA at bd.com. So uh I'm happy uh there's a number of references on the A couple. I'm not gonna show just right now uh in case you want to take pictures, but I'm happy to uh entertain questions. I do need you to come to the mic if you wouldn't mind right there in the center of the room by the projector. Uh Because this is being recorded. So we need to repeat the question if uh if you don't mind and I appreciate you asking questions. I kind of challenge some of you. Maybe you're not a believer, maybe you are a believer, but go ahead Jacob. Yeah, spot. Um So just a disclaimer. I work at a Providence Hospital in Orange County, so I work at Saint Jude. Um Mary Kay, I did wanna ask um what's the staffing ratio when they are in TT M? Because we are 1 to 2 at Saint Jude. And then um do you guys have any um dynamic uh real time hemodynamic stuff that you we that you guys have at mission? Because we don't. OK, sure. Those are great questions. Um So the um hemodynamic uh uh equipment we use is typically the um we have our arterial line that goes to an arterial pressure, cardiac output machine, the hemisphere. And so we're able to get cardiac output index, stroke, volume SVV, et cetera SVR. Um And then um in C in the cardiovascular unit, if their patients sick enough, they may put in a P A catheter. Um What was the other question? 00 Staffing. Our n our patients are one to ones while they're undergoing TT M. That's safest for the patient. You have frequent vital signs and neuro checks and everything that you need to do. Um You know, I I would call out if you can go to um there was a great presentation by Doctor Nancy Blake on STA on. Uh it was both the A EC and staffing um the guideline that just came out, it's hot off the press. They have it at the booth and then she also works at Los Angeles Medical Center and they developed criteria for 1 to 1 at a Los Angeles uh medical center uh with a group of nurses and staff. And so they have very select criteria about who should be a 1 to 1. Um I only got to see a couple of snippets of it, but you can also reach out to her and, and um she could probably share those guidelines for you. So that may be uh we do have one to ones with traumatic brain injury with C RT. I mean, you're gonna burn your nurses out really fast if, if you know that they're running C RT and a critically unstable patient and they have another patient while the other patients probably not gonna get a lot of attention. Right? Thank you, Jacob question. Hi, good morning. Uh My name is Joanne Wolfson. I'm from Central State Medical Center in New Jersey. Um You mentioned the neuron specific analyse. Um So I learned about this at the um A H A conference a couple of years ago. So I was very excited to bring that to my hospital. But what I found out was it's a send out. So by the time we actually get that result, the patients already rewarmed and, you know, decisions have been made. So I was just wondering if at your facility, does your lab run that test? So our, our neurons ana analysis is sent out. It usually takes 24 hours. Right. But what they do is they get the first one, they get the second one and that's usually by day three. Right? And then the third one is sent out. But they based on where they see those numbers going because in patients who are really severely injured from the arrest, their numbers are usually pretty high from the get go and sometimes they just continue to escalate. So we we don't do, we actually don't do neurop prognostication until 72 hours after they reach target or after they are warmed. So we actually delay it a couple of days. So it's actually done on like day five for our TT M patients. Ok. Thank you. Thanks John. Hi. Um Do you have any uh data about the uh TT M for cardiac arrest patient uh secondary to um drug overdose because there are some pay our physicians. Actually, I think we missed a lot of opportunities to start TT M because they were arguing about TT M increasing the metabolism and, and of course, you know, it delays the expiration of those drugs that the patient took. Right. That's a great question about TT M and drug overdoses as you know, nationwide. I mean, it is, it's awful what 100,000 deaths in 2023 from drug overdoses. The problem with drug overdoses is they typically respiratory arrest first. So they have this long period of anoxia and then they cardiac arrest. The people that uh uh respond and you know, pulse comes back. Cardiac, the prognosis is better if you have a cardiac event than if you have a respiratory event, you'll see the same outcomes in hanging patients. So if you've ever had a suicide attempt where someone or whether they're accidentally hung, um because there's that respiratory arrest and the anoxia that happens first, they generally do not have very good outcomes. So occasionally we have seen a save on a drug overdose rarely. Uh and we do do TT M on them, especially if they're, you know, 23 years old, we are gonna go through the t we're gonna give them everything we can. Uh But um I don't think there's anything that can help them except having Narcan at the scene uh when they do their drugs. Uh But yeah, it's, it's pretty bad. There's not a lot of hope, unfortunately. Ok. Yeah, I was curious. So you said that you delay neurop prognostication until 72 hours after they've completed rewarming. Um And then obviously, if they have ros um and our following commands initially after arrest, then you don't do TT M So um at our facility, some of our providers will after especially with out of hospital arrests. Want to give them a little time to see if they wake up and follow commands and then decide what they're gonna do. Is there an appropriate period of time? Because we felt that if it's not a hospital arrest and they don't immediately within a few minutes, like from a nursing standpoint, wake up and follow commands that that would be indication to go ahead and initiate TT M. But that's not always the um the decision that's being made. So we ty typically look it, the decision is made probably 30 minutes post ros, right? So if you have somebody who's, who's g they're purposeful in their movement, their G CS is seven, their pupils are completely normal. You know, maybe they'll kind of come around at 30 minutes. But if they don't, if they're not following commands, they, they'll probably get 3637 they'll get normal therm. But um because that's probably not the patient we would take down to 33. So, um yeah, it's probably about 30 minutes by the time we're instituting, you know, the intensivist comes down, the cardiologist is there. So, you know, gotta go to CT, you know, your comatose post arrest patient should have his brain CT before they go into the C lab because we had a patient who they didn't do that and actually erupted an aneurysm and had an arrest, 20% of aneurysm ruptures arrest as their first sign and they went to the Calvi instead because they had Tacos Subo syndrome and it mimicked a stemi, you know what happened when they gave Heparin game is over? Yeah. So you gotta go to CT. So usually within that time frame, we, we, you know, as we're gathering that information and we're preparing to go, um we'll start TT M so some places like Mike Mooney's place had the TT M pads on their interventional table. And so when the patient arrived, they slapped the pads on, on them in the C five, for instance, because they would go to the calf five pretty fast. So I think, I think, you know, those marginal ones, maybe you're just looking at normal therm if you're using a wrist stratification. Thank you. Thanks. Hi. My question is um when you discuss starting TT M within that 1.5 hours, you mentioned bringing the IC U to the Ed. Do you physically bring an IC U nurse to the Ed? Our Ed is at 200% capacity. So, like, do you, do you physically bring an IC U nurse to the Ed? So, uh I'm gonna answer that two ways um prior to the pandemic and the nursing uh loss of nurses. Yes. We used to bring our si or C IC U or cardiovascular IC U nurse down. Our rapid response nurse is also a formal critical care nurse and rapids respond to blues in the or so, they can, they help facilitate the starting. So when I say bring in the IC U to the bedside, it means looking at those interventions, we also included, er, nurses in our post cardiac arrest bundle build and review of evidence. So they're familiar with how important it is to start. TT M we have a checklist for the, er, and we have pads that are now in the, er, we have the Foley temp probe in the, er, so we put all the equipment down in the emergency department so it's accessible. Uh, but since the pandemic, um, and the loss, you know, our turnover was 30 some percent in critical care as people left to travel or left nursing or retired. Um, and we don't, uh, and our health system has put the screws on staffing down to the bare minimum. We don't have a spare nurse. I mean, half the time we're lucky if we get a break nurse to stay in compliance with California law. So, um, we don't usually have that CIU nurse that comes down now, but our rapid response nurse, since they have critical care experience often fills that role. Thank you. And in your case studies, um, you said they did both start TT M within that 1.5 hour period, but they both went to the Cath Lab on the same day. Will they go to the Cath Lab? Cooling? Yes, they go, they both of those started. Um, uh, they uh, gave them, I don't think they got ice Saline. Ice Saline can be a little controversial, especially with patients who have, you know, myocardial dysfunction. Um, so they put the pads on in the er, and start the machine. Yeah, they put the probe, they start the machine and then they go. Thank you. Thanks. So I was, was wondering, I'm at a small hospital and when we do 33 we rewarm to 36 degrees and then keep the pads on for the 72 hours and then take them off. And I know you mentioned when you do 36 you rewarm to 37. So are you rewarming from 33 to 37? Also, we rewarm from 33 to 37. But our target for the temperature is between 36 and 37.5 for normal. Yeah. So we just get some wiggle worm in there. And so it uh the machine we use is really good at sticking that number. And so um we rarely have any overshoot, but, you know, sometimes the work of the machine is pretty active. We used to do, I used to do 36 as a target and the doc said now we should, you know, we should go, sometimes they'll modify it and they'll say I only want you to go back to 36. So based on what they see and that their decision could be to stop at 36 but typically take them back to 37 and then for the 72 hours of fever prevention. Do you just do that by keeping the pads on for that time? There's a, a function in our machine that has monitor mode. So the pads are on but there's nothing flowing through the pads and, and then if they, their temperature starts escalating up, then the machine kicks on and, uh, then it works for normal therm. But we do the same thing with the pads on for 72 hours. My last question, how far, how high do you let their temp get before you start turning the pads back on? I think it's 37.5 that we set the machine or 38 something like that. Ok. Thank you. You're welcome. I do a lot of neuro tt M so I have to always think about neuro, no, cardiac rest. Good morning Mary. Um I'm from Kaiser Permanente Walnut Creek. Uh There is an argument a decision to be made by physicians if the patient is already hypothermic, like at 33. And because we used to use 33 degrees protocol, now we switch to like 36. So what do you recommend? Because there's an argument that we use 36 for a 33 already hypothermic patient. And the other question is, do we start tt M for a 33 degree patient already? Ok. So if they committed 33 the recommendation to the American Heart Association is you should stay there if you just stay there and, and keep them at that temperature and then do it for 24 hours. Um If you're gonna rewarm them, you need to put a device, hook a device up and rewarm them slowly because don't, don't rewarm too fast. And that, that's, you know, you're gonna get hypertension, you're gonna have all sorts of problems. Uh My recommendation is to stay at 3333. Ok, thank you. Thanks. Hi. Um, um, further, like I thought you do worse than I supposed to put like a bear hugger on them if they were being cool. Can you talk about that a little bit again? Sure. So actually we deploy the bear hugger, um, probably as soon as they get into the IC U, it's kind of hard to use it in calf lab. It's really not ideal. So, um, if they're going from, er, straight up to the C IC U, they usually pull out the bear hugger and they put it on right away because they know that they're probably good and be shivering. And so, I mean, it's pretty amazing because when you pull that thing back and then, um, you literally see the goose bumps come back and, you know, you got to do your assessment, you just throw it back on. So, um, we try that sometimes we'll even put socks on their feet, you know, and you can put hand warmers in. If you have those, we don't have any hand warmers. But, um, sometimes they put a little cap on their head. But, um, you know, just try to, you know, maintain some, you know, prevent shivering as best you can. So it's really good. It's, yeah, if you think about it, if you live in a cold climate, what is the one thing you do when you, if it's 30 or 20 degrees or 10 degrees outside, you start your car and the, you know, like the first thing you do is take your gloves off and put it on the heater. I grew up in South Bend, Indiana and I would sit in the car with my hands, you know, all over the heaters as it's blowing hot air and that would stop my shivering. Right. So, tricking the body is, you know, sometimes it works. Do you worry about rewarming them too quickly if you do it that way? No, because I'm, they're actually at the machine is controlling the ascent or the control of the temperature. So, the machine, you know, usually is still doing its job. It's responding to the patient's temperature and the changes. So you see that direct relationship with how it either takes the water temperature up or down. Thank you. Hi. Um, I think the hyperion trial broke out ages like 65 or greater in their data and it favored normal therm like all, all the way across the line. And I was just wondering if the other studies that you read extrapolated out age and if that plays a factor in determining which, yeah, because the this time period for looking at studies was pretty limited, I just put the outcomes of the C PC 12 for the entire patient population. But again, that's a risk stratification tool that you can incorporate into your hospital based protocol. And you know, our docs look at the risks, but they also, then they'll look at the age and look at the comorbidities. They'll look at the hemodynamic stability, you know, sometimes they start and they, they're too hemodynamically unstable. Their cardiac is, their heart's too sick and they can't, they can't do tt m all they can do is just keep them normal thermal. So there's a lot of factors that come in and age stratification uh might be one, you know, is one of them. So I just think it's up to your team to come to consensus, to look at the data and have all those trials, have the papers and, and whatever your team comes to. So your team may say if you're 65 and over, you know, 37 is ok. But if they've taken a neurological hit, you know, they, they may be OK and they may not, you know, because 37 doesn't control the, the doesn't affect the brain chemistry as much as the cooling. Thank you. Thank you. I think that that really speaks to the case studies that you showed too with, with the ages as well. Um We're right about time. I wanna thank you Mary Kay. This was fantastic. I, I wanna thank all of you guys for getting up early joining us today. Uh The spirit of advocacy. I hope that you are confident to start these conversations and find out what is best for your patients, what's best for your hospital. Please reach out to medical affairs and I want you all know that this program is gonna be featured on virtual NT I. So if you have coworkers that you're like, you need to hear what I heard. Um Please bring them on. There's gonna be an active chat in that conversation as well, but have a wonderful time at NT I. Thank you all. Created by
