Transcript Video Canadian Assoc of Crit Care Nurses Webinar on Targeted Temperature Control featuring Mary Kay Bader Mary Kay Bader identifies TTM studies and professional guidance released in the last year for protocol review. OK. Hello and welcome everyone. As we begin, CACCN gratefully acknowledges the indigenous peoples on whose ancestral homelands we gather, as well as the diverse and vibrant indigenous communities who make their home here today. The CACCN office sits on the traditional territory of the Anahi Abe, Hodahohoi, Ojibwe, and Chippewa peoples. This territory is covered by the Upper Canada Treaties. Please feel free if you would like to acknowledge where you are standing in the chat. So today our sponsor is BD Canada. BD is one of the largest global medical technology companies in the world and is advancing the world of health by improving medical discovery, diagnostics, and the delivery of care. The company supports those on the front lines of healthcare by developing innovative technology, services and solutions that help advance both clinical therapy for patients. And clinical process for healthcare providers. By working in close collaboration with customers, BD can help enhance outcomes, lower costs, increase efficiencies, improve safety, and expand access to healthcare. Our presentation today is targeted temperature management at your hospital bundled in current evidence or on thin ice. This presentation will focus on delivering care to the cardiac arrest and comatose postc cardiac arrest patient, selecting interventions, maximizing oxygenation, ventilation, and hemodynamics while implementing the strategies of TTM, neurological care, seizure surveillance, and management to lessen the pathologic impact of PCAS. The specific interventions and targeted goals, parameters will be discussed. Actual case studies will also be used to integrate the bundles into patient management. We are very pleased today to have our presenter, Mary Kay Bader, a neurocritical care clinical nurse specialist from Providence Mission Hospital, Mission Viejo, California. Mary Kay has 45 years of experience with an emphasis in neuroscience and intensive care unit. She is employed as a neurocritical care clinical nurse specialist working collaboratively with the team to develop protocols and manage care for neuro ICU patient populations. She has lectured nationally, internationally on traumatic brain injury. Hyper acute stroke, hyperthermia, and targeted temperature management, increased intracranial pressure, pressure, seizure, and status, spinal cord injury, aneurysm, subarachnoid hemorrhage, anticoagulation reversal in the presence of intracranial hemorrhage and postcardiac arrest care. We ask everyone to please put yourself on mute and turn off your camera. Questions unless indicated by the presenter will be held until the end of the presentation. Welcome, Mary Kay. We're very pleased to have you today. Thank you for the kind introduction. It's an honor to be here. Hopefully, you can hear me OK, right? Yup. All good. All right. These are my disclosures uh listed on this slide. I'm also currently on the board of directors of the World Federation of Critical Care Nurses and I'm a past president of the Neuro Critical Care Society and the American Association of Neuroscience Nurses. Our objectives are also um uh defined on the slide. I don't think I need to read them to you. I think you can read them, uh, fine. All right, so let's get into the, the primary subject of interest, and this is looking at patients who sustain a cardiac arrest. Now we know that once a patient comes into our institutions, whether maybe they arrested uh outside of the hospital and are coming in, or maybe they're in our hospital, they've arrested. The team is looking at, you know, while we're supporting airway breathing circulation, the provider team, the physicians are exploring what was the underlying ideology of the cardiac arrest. So there's sort of simultaneous things happening. We have the resuscitation efforts by the multidisciplinary team and at the same time they're looking at why did this patient arrest? Is it a cardiac reason? Is it a non-cardiac reason? What we are faced with at the bedside is once the individual has a return of spontaneous circulation, the changes that have occurred from that period of little flow, no flow, uh, perhaps minimal flow with uh compressions and ventilations is that we're left with something called postcardiac arrest syndrome. And this is an older definition. It's a unique and complex combination. Of pathophysiological processes including 4 key components. Those include systemic ischemia reperfusion injury. So we know that the patient has a loss of circulation. They go into anaerobic metabolism, but as that blood flow goes back up into the brain as oxygen is delivered into that tissue that has previously been ischemic, we have another form of injury that's occurring. These patients suffer significant hypoxic brain injury, and that is an overwhelming factor in the quality of their outcome that they're going to have following return of spontaneous circulation. Myocardial dysfunction, especially if it's a primary cardiac cause, we know that we still have to manage. Is this an occluded LED? Is this, uh, you know, what was the cause of the cardiac arrest and how has that impacted the heart? And then the underlying ideology of cardiac arrest. So I thought I'd start with two case studies and we're gonna follow these patients as we go through the talk. Case number one. A 63 year old male sleeping when wife heard snoring respirations. Now, when that happens to me, when my husband's snoring, I elbow him, you're snoring, get off your back. But in this case, she went to find a blood pressure cuff and came back, checked the pulse, and started CPR. So obviously, she saw something that concerned her, uh, and then she called 911. Uh, when the paramedics arrived, the patient. was in ventricular fibrillation. They did CPR for 20 minutes. They, uh, the patient received 5 doses of epi, amiodarone, atropine. uh, Rosk was achieved after 20 minutes. Glasgow Coma score was 111 on arrival in the emergency department. He was intubated. Um, we have a device called the pupilometer that we use to assess pupil reactivity and the, uh, NPI and the pupil. was 2.9 and 2.4. If you've never used this device, the NPI is a 0 to 5 number. Anything under 3 is significant for something going on in the brain, and something over 3 is considered normal. Uh, patients with cardiac arrest often either have no pupil reaction or a very uh low score, and it depends on how that score improves over time, whether neurologically that they seem to be improving. A 12 lead EKG was done which showed deep ST depressions in V1 through V6 and ST elevations in lead 1 and AVL. So he was classified as a stemmy. His blood pressure after Rosk was 91/52, a heart rate of 103, respiratory rate of 16. He was started on norepinephrine at uh and the drip is at 0.5 mics per minute. Now case number 2 is a 62-year-old male who was walking with his spouse when she heard a foul, and CPR was initiated immediately. 911 was called. EMS arrived within 5 minutes. The monitor showed ventricular fibrillation, gave one shock with return of pulse and sinus tachycardia. On arrival to the emergency department, his Glasgow coma. He was 241 for a total of 7. He was intubated. His NPIs on his pupilometer aren't bad. 4 and 4.2. The 12 lead EKG shows atrial fib with ST elevations in leads 23, and ABF concerning for an inferior wallstemi. Blood pressure is 128/69. Heart rate is 97, reps are 20, and he's on no drips. So, we're going to discover what temperature, what TTM we are going to do for these patients or how we're going to progress with how we're gonna uh manage these patients in the next 24 to 48 hours. So when a patient has returned to spontaneous circulation, there's a period what we call the 1st 120 minutes of immediate stabilization. So the priorities include focusing on mitigating the injury to the brain, um, looking at the, uh, is there adequate profusion, you know, adequate blood pressure? Is there adequate oxygenation, um, are they breathing? OK, what's their temperature? Um, are they having any kind of seizure? Because when there's a cardiac arrest, it not only affects the heart, it also affects the brain. And so we have to pay attention to these two organs equally, not just focusing on the heart, but as importantly focusing on the brain. So we need a comprehensive, structured. Multidisciplinary system of care that's going to help care for our patients. So we need to establish target goals oxygenation, ventilation, making sure our SPO2 is 92% to 98%. Our PACO2 is 35 to 45%. Our PAO2 is greater than 80%. We want a systolic blood pressure greater than 100, um, now in the United States, and I'll share. Literature, um, in patients who suffered a significant neurological hit, we shoot for immune arterial pressure greater than 80. That may be a little different than what you see in the Canadian guidelines. ECG shows uh uh we do a 12 lead, right, because we need to know within 10 minutes is this patient a Stemmy, and then there's consideration, you know, is this patient a candidate for TTM? Uh, targeted temperature management and if so, it needs to be started within 60 minutes of Ross. And then are they a PCI candidate? Are they going to need to go to the cath lab? So there's a quick airway breathing circulation check and uh getting our IVs established, getting fluids on board, uh assessing blood pressure, vasopressors. So the typical things that we're going to see in the immediate post uh resuscitation period. One of the things we always ask ourselves also is, you know, when we're examining the patient is what's their gla glaucoma score. If they're awake and following commands, well, number one, they're not going to need TTM targeted temperature management. They're doing fairly well. Their brain hasn't had that significant of a hit. They're awake. They're they're talking, they're communicating. We're going to focus on the other systems versus someone who's comatose, which represents an individual whose brain has taken a significant hit. So we're gonna triage those patients who are comatose, uh, generally reflected as a gla glaucoma score between 3 and 8. We're gonna focus on them and we're gonna focus on their neurologic care as well as their cardiac care. So in that immediate stabilization, supporting airway breathing circulation. So making sure that um if they're intubated, we do some blood gasses, we're monitoring SPO2 and PACO2. Circulation, we're looking at vital signs, we're looking at ECG rhythm, um, you know, what is the heart rate and blood pressure? Uh, is their blood pressure adequate enough? Getting the 12 lead EKG, uh, etc. So when we think about the, the need for TTM, there are a lot of recommendations out there in the post-c cardiac arrest arena, and we have to take a look at those recommendations and they're gonna differ country to country. Uh, so I'm gonna focus on some of the guidelines, the AHA guidelines, the AHA and Neurocritical Care Society guidelines, the 2024 Canadian guidelines, I'll mention the OCO guidelines, as well as several papers. So in the United States, our AHA guidelines which were um uh published uh for you. Years ago and then updated in 2023, it talks about that post resuscitation time period and the care that we are gonna provide our patients, which includes consideration of TTM and those uh recommendations are here which talks about delivering TTM between 32 and 37 degrees. Um, they also, uh, had, uh, this is just kind of blowing up some of the, uh, recommendations, uh, looking at airway breathing circulation. Um, you'll notice that the map in the AHA guidelines is at least 65, and I'm gonna share with you there's an AHANCS guideline. That says if if someone has more of a severe neurologic hit that perhaps their blood pressure should be supported with a little higher level like a map of 80. So there are some varying guidelines out there with different recommendations. Now there is a 2024. The paper that came out, the Canadian Cardiovascular Society and lots of other societies in Canada that made some recommendations. Um, this is expert opinion, um, some differences between AHA. AHA is really all it's driven hard by levels of evidence and quality of evidence, uh, so they really try to take expert opinion out of the equation, so to speak. But the uh expert consensus in this paper, uh they have recommendations for timing of uh coronary angiography. They also have recommendations for TTM blood pressure targets, oxygen and ventilation. So, you know, they, uh, differentiate the patients who need to go to the cath lab immediately versus uh maybe delaying angiography, uh, in out of hospital cardiac arrest without Stey. A temperature control initiate TTM ASAP, but in these guidelines it says the patient not following commands to target temperatures less than 37.5 and to continue temperature control for 72 hours. Now maybe there's some interpretation by varying physicians. I hope it's not let's see, we don't need to do it because that's the. Wrong answer, uh, but there should be consideration of avoiding fever and then the level that you're gonna go to is really should be dependent on the patient and their neurologic status, um, and I'll talk a little bit more about risk stratification in a few minutes. So this is a graphic picture from those Canadian guidelines. I think they did a nice job of, uh, you know, high. Providing the cardiac interventions, supportive interventions, temperature control, uh, and neuroprognostication and emphasizing neuroprognostication and not doing it immediately but delaying it 48 hours to 5 days and really should not be, uh, done early because the number one cause of death in postc cardiac arrest is the early withdrawal of care. Now the AHA came out with a 2024 focused update on ACLS looking at um interventions to support cardiac function post arrest, uh, but they also did clarify uh that if you see that quote, it is important to recognize that most enrolled patients in the trials and what they're speaking about is the Dankowitz trial which said there was no difference. Be in outcomes between 33 and 37, uh, but they said in those in those trials they had shockable rhythms with primary cardiac cause despite eligibility criteria compromising of both uh comprising of both shockable and non-shockable rhythms. These do not reflect the general population of post-re patients who survived to hospital admission in the United States. States where most initial arrest rhythms are non-shockable and arrests are due to respiratory failure, drug overdose, sepsis, and non-cariac causes. So, um, our guidelines have remained 32 to 37, but that means that the teams need to do a little bit more work. They need to investigate the studies and come to conclusion and consensus within their group, so. There are landmark studies with TTM, Bernard et all, uh, the hacker Group, those studies that were published in 2002 compared um TTM at 3234 to uh, just standard care, and by far the survival had improved when those patients were cooled down to 32 to 33. Now Nielsen's study that was published in 2013. Showed no difference between 32 and 36 and then the follow up study called TTM 2 by Dankowitz also came out with no difference in the outcomes between 33 and normalthermia, but I do want to highlight a couple things. First off, bystander performed CPR was 82 and 78% of the population. Bystander witnessed a. was 91 and 92%. 72 to 75% of those patients had shockable rhythms, uh, which we know have better outcomes. And when we look at the pupil reflexes being present, which is an indication that, you know, the neurologic kick wasn't so bad, it was 70 and 68%. The last thing you need to know about the the studies that were done in Europe is that. In the the EMS system in Europe is very different than the EMS system, for instance, in the United States, and I don't know what it's like in Canada, but in the United States our paramedics go to the scene. If they're an arrest, they do CPR, they continue CPR, they'll probably load and go, right? So they come to the scene, do the quickie valve, start CPR, shock if they need to, get them in an ambulance, take them to the ER. In Europe, it's stay in play. What does that mean? They stay at the scene and they do the resuscitation caught in the field, but very rarely do they load with the patient still under arrest. So we see patients who and our and our bystander CPR rates are. Abysmal compared to what they were in these studies, our patients, you know, we're lucky if it's 30% bystander CPR. So there is a very much of a difference in the the populations that we see in those studies versus the real world, and that's what the American Heart Association was talking about. There have been some studies, Nishikimi's study, which was published in 2021, looked at risk stratification, meaning if a patient had certain risk factors, did they do better, you know, where did they do better? Did they do better at 32, 33, 34, or do they do better at normal thermia or 36? And so they created what was called the RCA risk stratification. And when they did the RCA wrist stratification, they found that certain patients did better at 33. So you can see where the stars are. These are patients, um, good neurological outcome and survival at 30 days, and we can see that the patients who were called the 33 versus 36 did better neurological outcome when. They had a certain risk stratification, meaning their GCS was a little lower, their pupils may or may not have been reactive, so they looked at these specific risk factors and found that there is a group of patients that do better at 33 than 36. And then there's a group of patients with less severe neurologic injury that do better, that do fine at 36 degrees. And so when you look at this, this is that chart showing where it is. So this is about individualizing care to your patient and not just saying, well, look. There's a recommendation now we don't need to worry about this. We don't need to do that. I think that is incorrect. I think that's an incorrect assumption. Uh, I think that you really have to look at your patient's risk factors. There was also another study by Calloway in 2020 that looked at risk stratification using the PCAC, so it's a Pittsburgh, uh, uh, um. Cardiac arrest category based on the best neuro exam and the predominant cardiopulmonary failure and what was interesting is that they found that patients with less severe neurologic injury and less severe cardiopulmonary failure did better at 36 than 33, but more importantly, the PCAC at 33. Uh, or, uh, TTM, uh, PCAC-3 did better at 33 than they did at 36, and the PCAC-4s, um, did better at 33 than 36. So again, speaking to this risk stratification and so there are other studies by Bray. Bray was uh is a uh. Researcher in Australia, they had gone from 33 to 36. They went all in back in 2014 and they found out that their outcomes worsened when they went to 36. When you look at Johnson, who's from Harbor View in Washington, they flipped from 33 to 36, and their outcomes got worse, so they went back to 33. And then the protocol compliance has decreased significantly with the 36 uh targets. So this is Bray's study and this is Nicholas Johnson's study. So when we look at this, we have to consider our own patient population, what are the risk factors, what, you know, what is going on with our patients. So, um, the ILO guidelines in 2022 came out with recommendations. That say you know what, preventing fever by targeting a temperature less than 37 degrees, uh, it is a, you know, it's a weak recommendation whether subpopulations of cardiac arrest may benefit from targeting hypothermia 32 to 34 remains uncertain. Again, it's not just that you have a postc cardiac arrest patient. What is their neurologic condition? What is their. Cardiac stability. The Cochrane Review did a paper in 2023 related to hypothermia at 34 degrees, and on the key message, we asked whether people resuscitated from cardiac arrest benefit when their bodies are cool to a temperature of 32 to 34. Current evidence suggests that conventional cooling methods to induce hypothermia may reduce the risk of brain damage and improve neurological outcomes. Other studies, there's a Barker paper um out of Canada and the Journal of Cardiology, uh, and it recommended refining pathophysiologic out of hospital cardiac phenotypes who may benefit from TTM is an area of ongoing research. So again, they're, they're looking at that risk stratification. The German and Austria countries have stuck with 32 to 34, uh. The last Lascaro 2019 non-shockable PEA ayly French study saw better outcomes in the uh 33 versus 36 uh blank study. Um, this is in hospital rest. They had hypothermia at 32 is associated with a better neurological outcome at 90 days, and then, um Taccone did a study actually interesting with Dankowitz and the group. There in uh published in JAMA Neurology and they did this meta-analysis of the Hyperon uh the Laser study and the um TTM trial looking at PEA and a Sicily patient populations and they said look there's no difference but here's the problem the Laser study when they looked at the outcome CPC wanted to 2 is good to, you know. Uh, fair neurological outcomes, they included CPC 1 and 2. Well, the Taccone study only included CPC1 and compared them to CPC 1 in the 37 group. So I, it's not apples to oranges, and so I was a little dismayed at how that uh kind of study, it was almost like they manipulated it, um, to, to come out with, you know, equal numbers or whatever. Risk stratification, um, how do you do it? So at our hospital, our critical care docs came to me and said, Mary Kay, we want you to do a review literature. We want you to come up with some recommendations for cardiac arrest, and matter of fact, um, I, I know you can't see it, but I had to, uh. Drill it down to a little pocket card that they could put in their pocket after they listened to the presentation. And so what I did is I presented the Pittsburgh cardiac arrest wrist stratification and the Nishikimi wrist stratification. They chose. They liked the postcardiac arrest one. Uh, and also factors in, um, the 4 score and uh pupilometry data, and so our approach is that if we have patients who are following commands, who's purposeful. Pupils are completely normal, of course, we're just gonna prevent fever. If we have patients which are the PCAC2, they don't follow commands, but they have, uh, they have mild uh CP failure, uh, that was a witness arrest, they had CPR less uh CPR 10 to 20 minutes. Uh, they gave less than 5 Epis, um, TTM 36 to 37. A PCS of 3, which is coma with severe cardiopulmonary failure, they have high. Requirements they're on norepinephrine drips, um, their GCS uh motor score is 2 to 4, uh, and their NPIs and the pupilometer 22 to 4, and again with this CPR time at 10 to 20 minutes, um, we're going to recommend 33 and in deep coma maybe pupils are absent, uh, uh, motor scores of 1 on the GCS or a total GCS of 3 to 5, and these are unwitness arrests, long downtime. We're going to recommend 33. So we've taken a proactive approach, and this is our algorithm. That's what's on this card, uh, front side and back side. It's the risk stratification. I'm happy to share it with anybody if you're interested in it, but we've decided to take a logical approach to risk stratification and attempt to help guide the physician team. So if we come back to our cases, case. 1 and 2, which are both stemmies, and based on the risk stratification tool, um, perhaps you can see where we went with each of these patients. So case one, which was a V fib, slight delay in CPR start time, rest time 20 minutes, GCS of 3, pupilometer is less than 3, so it's net 2 to 4 range, uh, cardiopulmonary support with norepinephrine, and there are temi going to cath lab. And then case 2, which was the V-fib bystander CPR only lasted 5 minutes, higher GCS score, um, no additional support. Can you guess which one that what we targeted? So we'll go, go through it at the end. So, immediate stabilization continuing on, so I've done the TTM review, um, consideration of that TTM candidate should be based on the stratification and then initiating it needs to happen in the emergency department. You needed to move the ICU down to the ER and that means making sure the temprodes in place. You have a cooling device, making sure that uh the patient's adequately sedated with analgesia because you're not gonna get their temperature down. Uh, if they're shivering, it's gonna counter everything that you're doing and then having the provider select the correct or whatever they've decided for their target 33, 36, 37, whatever it is. Now additional interventions include seizure monitoring, so we apply a rapid response to EG headband device within uh 30 minutes of Ross because uh in comatose patients because we know these patients are at great risk for seizures. 20-30% of them will have seizures. A CT noncontrast scan of the brain is important. Even if they look like they're having a Stemi, they could have rupture an aneurysm, have takosubu syndrome, which presents with ST elevations and depressions and things that look like cardiogenic shocks. So you've got to make sure they don't have a bleed in their head before they're going off to the cath lab. And then if they were found. Down, making sure you uh protect your C spine and rule out any C spine injury. So the uh cardiac evaluation, the emergency department, consider a stat echo to look at uh cardiac function, uh, determining are they a PCI candidate, um, uh, do they go to the cath lab first and then I see you, or are they going to ICU next? Now another guideline that was published in 2023 is the AHA NCS guideline, and this guideline, um, was published, uh, in UNISON both in circulation as well as the neurocritical Care Journal, and this is, uh, I was, uh, part of this panel. It was a two-year initiative uh where we used expert consensus, so very similar to the. Canadian 2024 uh process for their recommendations and so we dealt with everything but TTM so we did not use TTM uh or have specific recommendations for TTM in this uh uh uh document. So there are 8 recommendations related to the neurological management in the ICU and so that speaks to that's where you see. On the second, uh, bullet, the target map of 80, unless clinical concerns of adverse consequences, uh, and where advanced cerebral monitoring is not routine, maintaining map at optimal in ICU is using monitors for cerebral autoregulation, uh, and then using pharmacologic and non-pharmacological strategies to lower ICP, uh, there are, uh, neurologic management, uh, recommendations. Uh, for seizures and non-convulsive status, there are cardiac, uh, recommendations which involves the mean arterial pressure, echoes, choice of vasopressors, mechanical ventilation. There's also, um, neurological management recommendations, um, and early triage, and then, um, uh, also specific recommendations for sedation, analgesia, etc. Uh, there's pulmonary recommendations, endocrine and fluids in the ICU, digestive system management, uh, the management of, uh, team-based care, uh, also infectious disease or infectious management and hematological management. So it really covers, uh, a, a very large breadth of care and um helps serve as it, it's helps serve as a basis for our postcardiac arrest care. In the United States, the Joint Commission, which is an accreditation body, came out with guidelines in 2022 that said hospitals must have multidisciplinary comprehensive postc cardiac arrest protocols in writing. You just can't pull out an AHA document and say this is our protocol, and it has to also address neuroprognostication. And so our, we did an evidence-based project. We actually reviewed. 177 sources of evidence that were listed in 23 PICO questions, uh, and we came to consensus as a hospital in the aspects of managing the comatose postcardiac arrest patients. So, um, the, uh, I, uh, one of the things that we developed was a series of bundles to help the team kind of condense all the information on patient management and so this is. Is the uh immediate 1st 120 minute bundle and the categories are oxygenation and ventilation, cardiac and hemodynamic optimization, consults, metabolic derangements, TTM early cardiac uh uh intervention, neurologic care and seizure care, and family and caregiver support, and so, um, we have, I've listed out the interventions that are. Specific to each of these categories as well as the parameter goals so um we use this tool in our emergency department on the other side, um, our, um, is actually a checklist but just to kind of highlight some of the uh important interventions, uh, airway and breathing, right, the intubation, mechanical ventilation, reassessing your blood gasses, making sure that um the. Patients adequately sedated before initiation of TTM is, is given. So remember, these are GCS 3 to 8 comatose patients. hemodynamics and blood pressure map, so we um do encourage a map greater than 80 unless there's cardiac compromise and it would hurt them to use a presser to raise their blood pressure. So we're very aware our cardiac colleagues have to uh chime in. Cardiac catheterization, so those patients appropriate for the cath lab. TTM induction within 120 minutes. There was a study 13 years ago by Mike Mooney out of Abbott Northwestern in Minneapolis that showed every 1 hour delay in initiating. TTM to 33 resulted in an increase of 10% mortality. So you want to start initiating your TTM management immediately, uh, and getting, you know, the decision made and uh starting to deploy that in the emergency department is very important. Uh, neuro seizure control, so getting the rapid response EEG, making sure that we're monitoring for non-convulsive status epileptics, and then monitoring their labs, um, uh. This is the checklist that our emergency department uses, and it was devised by our nurses, the staff nurses that were on our collaborative that we had, and they wanted very specific things like where the equipment is located to make it easy for the, for the team. Now back to case one and case two, both of these patients who are stemmies, case one, the TTM was initiated, uh, a target of 33, uh, was met within 2.5 hours. They went to the cath lab. They had a less circumflex 90% occlusion treated with a drug eluting stent. Uh, and then, uh, the patient went to the ICU. They had, uh, TTM for 24 hours. They were rewarmed at 0.25 degrees per hour, and then fever avoidance times 72 hours. Case number 2, TTM was initiated to a target of 36 degrees. In the cath lab, they found 100% occlusion of the right coronary artery and 90% stenosis of the left AED left AD. Uh, uh, and, uh, he was treated with a staged approach. He had a drug eluting stent placed on the day of arrest and then another one placed on day 10. Uh, the patient management, the ICU included TTM, we still use our machine to control. Heck, we use our machines to control normalthermia in our brain patients, our, our TBI patients, our, our, uh, stroke patients that are like subarachnoid hemorrhage. We don't let them have a fever, so we maintain with our device on our patient to maintain normalthermia, uh, and we do fever avoidance. Now the critical care. Phase protocol, uh, looks like this. So we have oxygenation and ventilation, the bundles again, cardiac and hemodynamic optimization, TTM maintenance and rewarm because initiation happened in the emergency department, cardiac workup, neurologic care, seizures, surveillance management, metabolic arrangements, neuroprognostication, which uh we advise not to occur until 72 hours post TTM uh and. Family and caregiver. Once again, all the interventions, so you'll see for instance under TTM that we use short acting drugs like propofol and fentanyl that we deploy shivering assessment on an hourly basis or every 30 minutes when they're rewarming uh just to make sure that um if they start to shiver that we're going to control it. We rewarm them slowly at 0.25 degrees an hour. As you rewarm somebody, you increase cerebral blood flow every 1 degree. It goes up 8 to 10%. And so if you have somebody who has a compromised brain and you be warm too fast, you can actually, it's not just the shifting of electrolytes, but it can worsen increased ICP, um, and this is off subject of cardiac arrest, but, you know, I, I just got an email from a friend of mine who lives up in Boise, Idaho, and she says, we've been seeing a lot of people down in the snow this winter, and they come on super cold, like 22 degrees. I'm like, what. what? Uh, and she goes, Well, how fast should we warm them? And I said, Well, you know, you have to be very, very careful. I mean, you need to get them up to a certain point, but when you're like in the 30s, you need to rewarm them like if they've not had a cardiac arrest, but like a half degree an hour because you're gonna get shifting of potassium and all those electrolytes as you rewarm. So you have to be very careful. Uh, so we rewarm slowly because, you know, potassium is going to increase mag calcium, we'll got they all. Go from inside the cell to outside the cell when they rewarm, um, if they, if you're doing uh uh insulin drips, they are gonna get hypoglycemia because they're, they're cold, they're, uh, insulin resistant when they rewarm their blood glucose drops, so lots of important uh interventions and monitoring that has to happen in the uh critical care unit. Uh, and so shared decision making is very important with the uh uh the family. Significant others and the multidisciplinary team. And then again we have parameters for outcomes. Uh, in this patient population, this is just breaking it down so it's a little bit more visible so you can see oxygenation, ventilation, and meds. Uh, we try not to use paralytic agents. We usually do it a bolus when they go down and maybe when they're coming back up because they have a tendency to shiver when they go between 34 and 36, but actually even patients who are targeted at 36 can do a fair amount of shivering. Uh, we have, uh, parameters, you know, when you rewarm somebody, um, they're the, uh, when they're cold, they're pretty stable with their blood pressure, but as you rewarm, they vasodilate, so blood pressure drops. Um, your heart rate is usually slow when you're cold, as you rewarm, it'll go up. Um, so, you know, different things that we're looking for and that we have the nurses to, uh, monitor. That rewarm phase, I personally believe is the most dangerous. Phase when you're taking somebody out from a lower temperature to normal temperature and um that's because you know they vasodilate their blood pressure drops. They have electrolytes that are shifting um and you really have to pay attention. If they're gonna have seizures and non-convulsive status, it is more likely to emerge during the reborn. As you rewarm them, their brain is gonna get very angry and you're more than likely to see non-convulsive status epilepticus during this time. So neuro assessment and monitoring and the management of these patients as you rewarm, they're more likely to have increasing uh cerebral edema. You will probably see pupils that may have been reactive uh when they were cold go non-reactive as you rewarm. Uh, so assessment and monitoring of the neurologic exam is important. Uh, doing continuous EEG monitoring is important. Uh, uh, use. Seeing different devices like we have pupiometry and there are many studies published on outcomes with pupiometry um found to be very uh exact and uh predictive of poor outcomes, uh, so especially in NPIs lesson two, and then interventions, uh, management include head of bed at 30 degrees, uh, making sure to alert the provider when there's abnormal or. Changes in the neuro uh assessment and then um administering certain medications. EEG monitoring is, is absolutely essential in these patients because there is such a large number of patients that do sustain non-convulsive status epilepticus, uh, and so we need to be aware of it and be able to treat it. So assessing, uh, and intervening for these patients who do have seizures or non-convulsive status. Neuroprognostication is the last component and that neuroprognostication, um, we prefer that physicians not do it until um 3 days, uh, 72 hours because, you know, if you, uh, I have seen people who you never thought would survive, who survived and woke up, so it, um, you know, it, it should be delayed until um we're able to get all the meds out of their. and that we can truly have time for their brain to, to do some recovery. Uh, the Canadian Cardiovascular Society does have a position statement where they recommend and when they recommend uh neuroprognostication, and that's between 48 hours and 5 days. And so many of the tests that our standards are very similar between the uh 22 countries actually internationally. They're pretty consistent. So, um, clinical exam, SSEPs, EEG, biomarkers such as neurons specific analysis, we draw them every 24 hours for the 1st 3 days and then imaging CT and MRI. So the summary and outcomes of our two cases, case number 1, 63-year-old male with prolonged CPR. His hospital length of stay was 40 days. He was discharged home with home health, and he's alert, he was alert and oriented. His Coco home score is 15, and he was at baseline, um, from to his prior arrest status. Case number 2, the 62 year old with CPR times 5 minutes. His hospital length to stay was. 13 days he went to the acute rehab unit. His neurologic status ended up as 465. He did have some physical therapy mobility issues. He's using a walker, uh, working with PT on ambulating and stair training, and, um, with occupational therapy, he's impulsive and highly distractable. He does respond well with cues. You can tell this came right from their final report, and he's also working on ADLs. So, um, don't forget that a very important component of, uh, managing post-rest patients is keeping track of your data. This is a requirement in the United States with the Joint Commission, um, and I will tell you, people that say, oh, we don't do TTM, it's not important. Have you looked at your data? Have you looked at your outcomes? And I would tell you that people who don't track their outcomes, we've been tracking outcomes in postc cardiac arrest, TTM patients since 2005, so I have almost 20 years of data. We do a 100% review, and that's reported on a quarterly basis. How do you know? The outcomes whether TTM is good for your patients or not if you're not tracking their outcomes. So very important, it's how we know what we need to work on to improve as a multidisciplinary team. Well, I'm, I'm happy to entertain any questions. Uh, my email is beermk@aol.com. I am more than happy to send you, uh, protocols or cheat sheets or the card uh template, uh, whatever you're interested in. And uh there is also uh important information that you can receive from BD so that is um listed on this and in the slide deck, the last couple slides are actually references, but I'll leave this one on. Thank you. Great, thanks so much, Mary Kay. That was really interesting. Um, so does anyone have any questions? Feel free to turn on your camera, um. And uh Ask away. So let's see, I'm just looking at the chat. Raymond says, thanks Mary Kay for your informative presentation. I have 3 clarification questions. First one is with regard to the duration of TTM, is it 24 hours from the initiation of the protocol or 24 hours from the time the temperature of 33 is achieved? Great question. Uh, it's 24 hours after you hit target. OK. And the second question is, do you also initiate EEG monitoring even on patients on sedation, i.e. Pro propofol or fentanyl? Oh, absolutely. Um, your, your, I mean, the, the neurologist will be able to discern, uh, you know, the effects of sedation or not enough sedation, but more importantly, if the patient's having non-convulsive status, they're gonna see it. They'll, they'll see the, the extra beats or the extra waves indicative of a very angry brain. So yes. OK, and the third question is, I would like to ask the reason for initiating insulin infusion once the target temperature is achieved. Can it not be started sooner? That's a great question, and it actually came from our own personal experience. So we had, uh, we were really aggressive with insulin management and postcardiac arrest and what was happening is That we would start it right away. The temperature's going down, and when your temp's going down, your electrolytes go intracellular, so your potassium drops, you know, it could be 4, it drops down to 2.6, and what was happening is that when you're cold, you're insulin resistant and so the nurses were increasing the insulin drip, increasing the insulin drip. They were at 10. 1, 2030 units of insulin, they're not getting anywhere. And what was happening is that the potassium was going down to like 1.9, 2.0, and no matter how much potassium we're giving the patient, we couldn't seem to give it up. And so we, we called it hypo hypothermia induced, uh, uh, potassium. Something uh imbalance. I, we called it a a hippie for short and um we found that what we surmised is that when you have people with high potassium, one of the things you do is you give D50 and insulin, right, and it drives potassium into the cell and so our theory is that uh in the presence of of high glucose uh and then. You're, uh, giving more and more and more and more insulin and your insulin drips. So anytime we would see insulin drips going past 10, we saw this phenomenon. And so in order to, to stop that, we wait until they settle down at their target temp and once they're there and you got systems sort of stabilized, then we start it. But you know, if you're, if you have a really resistant type 2 diabetic and you're increasing, increasing, increase, you better be very careful when you start rewarming because what's gonna happen is they're gonna have hypoglycemic episodes as the insulin resistance wears off. So we did it as a very specific uh solution to a problem and we stopped. Seeing that we factory low potassiums because then what would happen is you'd, uh, um, we literally would uh shut the insulin off or cut it like I remember this one case we cut it in half and then we shut it off and I think the insulin drip was like at 20 or 25 units and the potassium went from 1.9 up to like 4. Almost the, you know, within a couple of hours. So, uh, we decided to take that kind of pause, let them stabilize, uh, uh, there's, it's hard to find evidence of that, uh, uh, a lot of write-ups on it, but there are, there is some literature about it. Excellent. Thank you. Um, another question is, are you able to share the link to the guidelines for TTM and postcardiac arrests that you use in your hospital? Oh, sure, uh, uh, you, I can, if you email me, I can send you our protocol. Um, and I include the, uh, uh, Hirsch article from circulation, if that would be helpful. Or if you want to send it to me and OK, then I'll just include it in our email when we send it out tomorrow with the survey. Um, someone else is also asking for the reference list from the presentation, if that's not too much trouble. I'll send you the PDF of the presentation that has the reference. Perfect. Does anyone else have any questions? We're getting lots of comments about, oh, question coming from rural hospitals in Saskatchewan. Post ROSC patients would be generally transferred within 1 to 24 to 4 hours, sorry, to tertiary centers. We don't have a device for cooling. We have been starting with cold packs, removing humidifier from vent. Any other suggestions? Uh, that's a, that's a, that it is a quandary when you have to transfer. You have to be careful, um. Ice packs are OK, but you have to be able to monitor the temperature continuously. So if you, if you're gonna be transporting the patient, they need a method. We, we had a patient that arrived once from an outlying hospital that they had packed in ice, and the patient arrived with a temperature of like 29 degrees, so, uh, Celsius. So you gotta kind of be careful cause when it's good to. Start like ice packs in certain strategic areas, but you also have to monitor where the temperature is going, uh, but I do know that that is a bit of a challenge. Um, So, probably, I would just stick with your ice packs and then monitoring the temperature, but, and being aware that it could go down low if you use too much ice. Um, the follow-up on that was, uh, we can do esophageal and rectal, I'm assuming temperature management, right? Mhm. You can, uh, you can, uh, monitor the uh temperatures that way. Excellent. Um, any other, oh, yes. Any other questions? I'm often asked about chilled and asked for cooling, right? Apologies if I missed it. Do you have any guidelines do any of the guidelines address yes. There are, um, there are guidelines against using ice saline in the pre-hospital field. Um, they, they don't recommend that. Um, we occasionally use uh ice saline bolus of 30 ccs per kilo, uh, uh, and through, uh, antecu. peripheral lines, uh, but it really depends on the cardiac status of the patient. So sometimes, um, we won't, we won't give it, especially if you have heart failure history, or we'll, um, may give only 1 L or 500 ccs or something like that. So, uh, there's variable. Can help you get down a little faster, uh, but the, probably the best, most accurate is, is having some kind of system that you apply that has a feedback loop so that it's monitoring the patient's temperature as it descends and then changing the delivery of the cold fluid through the system so you, you don't go past your target. OK. And also, do you use icy cat or blanket systems? We use a sticky wrap system. I'm not a big fan of the um I'm not a big fan of those things that you put underneath them and they just sweats and they get wet. Um, intravascular systems, uh, if you look at the literature, and if you look at the evidence-based recommendations, the evidence-based recommendations are either an intravascular device or a Gel pad wrapped kind of device. Those are those devices have been studied. They are found to be the most accurate in controlling temperature. I've seen too much patient variability when you're just using something circulating on their backside. So, um, but that's my personal experience, but there is evidence recommendations in the literature for those two. Excellent. Thank you. Um, any other questions? And I will say to you that the reason we chose the gel pad system was that it was a physician decision. They were community hospital. If the intensivist is not immediately available to drop in a vascular line, they did not want to delay the initiation of TTM, so that's why we went with the system we went with back in 2005. Awesome. OK, um, in the interest of everybody's time, if there are no other questions, and we're going to just wrap it up. And last call for questions. OK. Well, thank you very much, Mary Kay. This was an excellent presentation and thank you to BD Canada um for sponsoring this event. Uh, watch everybody who's attended or registered, watch for the post webinar survey link to be sent out tomorrow via email along with an open access link to the webinar. The webinar will be available open access for approximately 7 days, so you can let your colleagues know to watch um our Facebook, LinkedIn, Instagram, and X account uh for the access link and the password. So thank you again, Mary Kay and BD and thank you everyone for attending. Have a great rest of the day. Bye-bye. Created by
