Serena Kelly presents relevant clinical information related to Targeted Temperature Management (TTM), as an important therapeutic tool in the care of critically ill pediatric patients.
Welcome. I'm Colleen bland and a part of our medical affairs faculty. Today I am excited to share a clinical jewel has joined us to share her experience and wisdom working with our world's greatest resource our kids. Serena kelly has assessed Children of all ages working as a dual board certified family and acute care pediatric nurse practitioner bringing her stories from emergency and pick you. She is always advocated for the highest quality of care and practice. She has been recognized by her hospital as a nurse of the year, her city top advanced practitioner and a CNN into their Circle of excellence serena instructs as an assistant professor of pediatrics and author. Her current scholarly interests includes the role pediatric thermoregulation plays in promoting recovery and using hi Fi simulation. Serena has both created and led a pediatric I. C. U. T. T. M. Program whether you relate to her clinical responsibilities or are inspired by her professional role modeling. It is with great pleasure. I introduce your pediatric nurse expert, Serena kelly, thank you so much for that lovely introduction. Um I want to thank all of you for taking the time to listen to me speak on this topic. I find it very fascinating and very important mainly because it's a nice bridge between providers in that bedside nurse and I am a nurse at heart. So we're going to talk about pediatric targeted temperature management or T. T. M. Time is Brain. I'm a pediatric acute care nurse practitioner at Oregon Health and Science University which is located in Portland Oregon. Specifically. I'm in dorm Becker's Children's hospital which is a part of O. H. S. You and I work in the Picchu. We are a level one trauma center also Gold Center of Excellence for ECMO And we have a mix of medical, surgical and cardiac patients in our 20 bed icu. I've been in nursing for 20 years in the last 14 as a nurse practitioner and I've spoken nationally and I really love sharing this topic or disclosure. I am a paid consultant for B. D. And this presentation consists of my expertise and knowledge surrounding T. TM. And pediatric critical care. I really wanted to start by recognizing that T. T. M. Is not easy and it can be controversial. There is no panacea. What's important is ensuring that we optimize care in Children, post arrest and when appropriate in neuro critical care Children. T. T. M. Is an important component of a post cardiac arrest or neuro critical care bundle. And it's really important to recognize it's part of an overall bundle. The pediatric resuscitation quality collaborative pd rescue is a really great resource with the goal to sustain discovery analysis and publication of medical science leading to evidence based CpR guidelines and improve survival for Children. The other important part to mention is that A. H. A. Has also multiple resources to summarize the best evidence for optimizing post cardiac arrest care. We often focus on labs, chemo dynamics sedation. But T TM. Is a complex intervention and requires expert bedside nursing, specialized equipment and close medical monitoring. So it really brings in all the components that is so important when you're dealing with a child and the pick you team has to come together. The three main objectives of this lecture is to recognize the role of T. TM. In the overall care of Children. To review the current evidence available on T. T. M. To discuss the barriers, challenges and controversies of pediatric T. TM. Which there are some. So what is T. T. M. Targeted temperature management? Targeted temperature management refers to the continuous maintenance of patient temperature within a narrowly prescribed range. While continuously monitoring temperature all forms of T. T. M. Avoid fever and hypothermic targeted temperature management attempts to treat re profusion syndrome by decreasing metabolic demand, reducing free radical production and decreasing apoptosis. So, I wanted to start by sharing literature and like many things in pd things in pediatrics, the literature in the adult world is what often we have to look at to support taking care of Children in the best way possible. So there is a great deal of literature in the adult world, supporting targeted temperature management and I'm just going to highlight a few like much of pediatric medicine, we can extrapolate some of this evidence to Children in 2000. The Haka study hypothermia after cardiac arrest was published, they initiated cooling in the emergency department within 62 minutes and the goal was 32 to 34 degrees for 24 hours. They found that cooling was feasible and safe CPC scores were better compared to controls measured at six months out. So, given that we do need to touch upon what is a CPC score. A lot of studies use CPC, which is the cerebral performance categories scale and it's a gross measurement of performance. Um so a CPC of one is good cerebral performance. The individual is conscious, alert, able to work. They might have some mild neurologic or psychologic deficits. CPC of two is moderate cerebral disability, so someone is conscious, they have sufficient cerebral function for independent a DLS. They're able to work sometimes in a sheltered environment and CPC of one and two in most manuscripts are considered good outcomes. But note the very big difference between each score, that's one and two. Then you get to three where there's severe cerebral disability. Someone is conscious but they're dependent on others for daily support of a DLS because of impaired brain function and ranges kind of vary from ambulatory to severe dementia or paralysis. And then CPC of five is essentially brain death. So, as we're looking at this, the studies oftentimes CPC comes up In 2002, the New England Journal of Medicine published a start study by Bernard at all. And it was the treatment of comatose survivors of out of hospital cardiac arrest with induced hypothermia. There were 77 patients in Australia that were randomized at 33 within two hours of Roscoe or 37. They use midazolam and vecuronium to prevent shivering. And I pull that piece out because it's really important that when T. TM is done, we prevent shivering to decrease that metabolic demand and make sure we're not counter um countering our the good benefits of T. T. M. With allowing shivering. The 33° group for 12 hours. Had 21% of survivors with better neuro outcomes compared with a 37° group that had 11% with good neuro outcomes. In 2013, Nielsen had a landmark study that came out and it's the T. TM one study. This study really changed practice across the nation in a lot of other countries as well. Looking at hypothermia versus targeted temperature management at mild hypothermia. And really a lot of questions came out of this study. Some of the questions were, is it hypothermia or prevention of fever That is impactful for our patients. 36° is actually not normal therm. Eah, but in fact mild hypothermia. And looking at temperature curves of this study really, the study avoided fever of 38. There was no survival advantage found between the two arms of 33 versus 36 as far as neuro outcomes go CPC scores were not statistically significant between the two arms. There were some issues that were brought out by those who really delved deep into the study. One is it took 12 hours to get the to the target temperature of 33 degrees versus four hours for 36 degrees. Cpr time is actually one minute after arrest in this patient population because it was done in a different country. A lot of the patients enrolled were patients from Sweden for example. And in Sweden in 2011, CpR Bystander CpR was administered in 70% of these patients versus the U. S. Where this occurs in 32% of patients. So the time to a CLS in a lot of these countries to are these studies um enrolled patients was time to a C. L. A. CLS of 10 minutes, which is very quick. This study also included P. E. A. And a sisterly patient. So this study really started to change and flip people from moving away from 33° to 36° and from that and having all this great data from the adult side. There was a push to make targeted temperature management standard of care in 2015 circulation. The A. H. A. Part eight post cardiac arrest care recommendations. What came out and recommended 32- 36°. In 2017. The American Academy of Neurology also made some recommendations of 32-34 for 24 hours after ventricular tachycardia ventricular fibrillation in out of hospital cardiac arrest for those who are still persistently comatose. They also recommended it for a sisterly R. P. A. Of 36 degrees for 24 hours, followed by eight hours of a re warmed to 37 degrees and persistent avoidance of fever. So T. T. M below 37.5 for 72 hours. In 2017, a study came out from Kierkegaard talking about out of hospital cardiac arrest in shock, kable and unshakable rhythms. They had 33° for all enrolled for either 24 or 48 hours and found that maybe mortality was reduced in the 48 hour group, possible improved CPPCC scores of 1 to 2 in the 48 hour versus the 24 hour group. But overall, the sample size was inadequate to really say for sure. So what you see in the evidence is a trend towards increased improved cPcs, but sometimes not statistically significant. In 2017. Out of Australia, there was a study by Bray at all that looked at ventricular fibrillation and out of hospital cardiac arrest patients, They changed actually, temperature management from 33 to 36° because of the TTM study. And they went back and looked at was there a change in outcomes before this Did before the 33- 36 change. And what they found was with this change of moving instead of doing 33° for this patient population and using 36, there was actually lower hospital survival. Those who did survive had lower CPC scores lace lace less patients received active cooling overall, they had less time at the targeted temperature prescribed temperature and fever rates were actually increased overall. So some of the discussion that comes out of this particular study is that 33° can be easier to maintain than 36. 36. often requires adequate sedation and sometimes muscle relaxant relaxant to avoid fever for lots of reasons and we'll get into that a little bit more as well. In 2019, the French hyperion trial came out in the New England Journal of Medicine and this was a trial of 584 adults at 25 sites with non shock kable cardiac arrest. The intervention was the 33 degrees arm versus a 37 degree arm. And there was good neurologic outcomes. So a CPC score of one or two in the hypothermia group of 10.2% versus the normal author. Me a group of 5.7%. This was a difference of 4.5% in a P value of .04. So the hypothermia group had a higher survival with better outcomes. So all these studies really like anything else. When you really delve into the literature, there's always so many more questions that come out when you really look at it and this literature is pretty well done. So after the adoption of 36° targeted temperature. Since the TTM trial, there was a group in New Zealand and Australia in 2018 that reported an increase in prevalence of fever compared to historic treatments. At 33 there was a demonstration of lower protocol adherence and a trend towards worse outcomes. Why is that? Well, once again, T. TM is a component of a post arrest bundle. Not only that, but the delta between 33 and versus 36. Hitting that fever of 38 is much smaller. Right? So physiologically as well. 36 is very close to the body's natural shiver response. So what is often discussed by the bedside practitioner who's actually utilizing targeted temperature management at the bedside is the challenge of implementation and sustaining a. T. T. M. Of 36 compared to 33 in this study. The supplements actually suggest minimal changes to the protocols other than prescribed temperature but they were unable to assess true protocol adherence. So the University of Washington in 2020. So let's look at the United States in Critical Care Medicine, johnson at all, looked at adults out of hospital cardiac arrest. This is a single tertiary care center that also changed their protocols from A. T. T. M. Of 33 to 36. In april 2014, Their end was 453 patients. It was a retrospective cohort study. And they did and they looked and said 258 patients received T. T.M. at 33°. They looked at the 195 after the change to 36° 33° had higher odds of neurologically intact survival. So 40% versus 30%. However there was no difference in overall mortality. So should targeted temperature management at 33 be put by the wayside and completely focused on 36. Not necessarily. So there might not be a difference in survival but there could be a trend towards a difference for those who do survive have better neurologic outcomes. And that's really what we want for our patients. So T. T. M. Two came out which is why we talked about T. Tm one and TM two. So in 2000 and 2021 in the new England Journal of Medicine. So Super fresh and new. There was 1580 adults who had out of hospital cardiac arrest 930 were put into T. T.M. 33 931 were put at 37.5. So, true normal author Mia. The important part on this is that they had warned active warming or cooling and they had active fever prevention. The 33° group did not have a lower incidence of death compared to the 37.5 group at six months. As far as functional outcomes go. The functional outcomes were the same in both groups. Once again though, this study is looking at a population more in europe rather than the U. S. So the same questions still apply. Can we take that population and apply it to our U. S. Population? So all this information from the adult world kind of pulls us towards, there could be a tendency towards improved cognitive neural outcomes if you use targeted temperature management in adults. What about Children In 2008, Hutchinson at all had an article in New England Journal of Medicine, hypothermia therapy after traumatic brain injury in Children. So in Children, pure cardiac arrest just doesn't occur as often as in our adult population. So how much are we able to look at Children and study Children to see the potential impact or lack of impact in Children? Well, the Hutchinson Multi center trial looked at 96 pediatric patients with a GCS of eight or worse at the scene of injury. They initiated moderate hypothermia within eight hours of injury and maintained it for 24 hours. The study did not show an improvement in neurologic functional outcomes at six months. They used gross functional assessment. So in Children they used the Glasgow outcome scale, extended pedes instead of the CPC scores to look at how do they function after these events if they survive and there was not an improvement from what they could tell. However, there were also, you know, questions was the duration of therapy to short eight hours after injury is typically a little bit long. Most studies have been showing that initiation within four hours is kind of the optimal spot to get benefit. And was the duration of therapy too short or was the outcome potentially important because we're preventing fever. In 2013, in the Lancet, there was a multi center multinational study comparison of hypothermia and normal author MIA after severe traumatic brain injury in Children, the cool kids trial And they were enrolling Children with non penetrating brain injury. So, a Glasgow coma scale of 3-8, They enrolled these Children within six hours of injury and they put them into 32-33 for 48-72 hours a little bit longer versus 36.5-37.5. The trial has actually stopped after a futility analysis in 2011 because there was no difference in outcomes in this patient population. Then came the Fabrica trials. So in 2015, the therapeutic hypothermia after out of hospital cardiac arrest in Children or tabqa for short, came out and this had very strict criteria. The patients that were rolled had to have at least two minutes of cpr have a persistent coma, mechanical ventilation and a gcms of less than five, which means absent response to deep pain. So these Children were put into either t tM of 33 degrees hypothermia versus targeted temperature management of 36.8, which they described as normal for MIA. The primary outcome was looking at the vinland adaptive behavior scale. This is a great scale and is much more specific to the evaluation of cognitive state than more gross measurements like the G. O. S. Extended piece. And there are some limitations with this study as well. But they were looking at vinland adaptive behavior scales, outcomes at 12 months and it was 20% versus 12% for the 33 versus that 36.8 group. The p value, however, was 0.14. So the observed difference of 8% was not statistically significant, But it could be clinically significant if this were a true difference. The big thing that came out of the step to trial was that we were able to show or prove that 33° can be done in a safe manner for Children. So in the early 2000's, when you know, these studies were kind of happening, the control groups were usual care, which with fever being very common actually, that could use normal author Mia, which likely decreased the over all effect size that was observed. So, one of the common themes is these studies were actively preventing fever and the best way to do that is using T TM is part of that overall bundle. In 2017, the same group published their tabqa information but looking at in hospital cardiac arrest for Children, They randomized 295 pediatric patients within hospital cardiac arrest. Um and looked at uh 33 or 36-37.5. The data showed no significant difference in the primary outcome between the two groups. What's interesting to notice with this is that this is not surprising for those of us who do Children who have pediatrics is kind of our thing is that only 8 to 10% of population in this study had shock kable rhythms as opposed to the adult studies, where there is 80% who usually have shaka ble rhythms and of those who had shock kable rhythms. The ideology was often congenital heart disease in the hospital, which completely makes sense. So there's a small number of cardiac arrest patients with a cardiac ideology in these trials but the common theme still is avoidance of fever. So what does that really mean? What do you do with all this information? Well part four of the A. H. A. Pediatric basic and advanced life support recommendations actually came out and the post cardiac arrest brain injury still is the leading cause of morbidity and mortality in adults and Children. Because the brain has limited tolerance for ischemia. Hyperthermia or Dema pediatric. Post cardiac arrest care focuses on anticipating identifying and treating this complex physiology to improve survival and neurologic outcomes. Well Part four from the A. H. A. States that resuscitation does not end with the return of spontaneous circulation. Excellent post cardiac arrest care is critically important to achieving the best patient outcomes. four Children who do not regain consciousness after Roscoe this care includes targeted temperature management and continuous basically E. G. Monitoring the prevention and or treatment of hypotension, hypoxia or hypoxia and hyper cap nia or hypoxia apnea is important. So all the components need to be done well. So we can have the best possible outcomes for those who survive. Part four also speaks to infants and Children between 24 hours and 18 years of age who remained comatose after out of hospital cardiac arrest or in hospital cardiac arrest. It's reasonable to use either T. Tm. Of 32 to 34 followed by T. T. M. Of 36 to 37.5 or only 36 to 37.5 nowhere in this is it okay for us to allow Children to become fibrin. So we've talked about adult data, we've talked touched on some of the pediatric data and for me as a nurse practitioner and someone who's at the bedside that really finds seeing how these Children do in the I. C. U. And I. And knowing that what we do is important not just for survival but for outcomes. I feel like years ago it was often times like okay we're the ICU. Our job is try to get these kids to survive but really it's not. We have moved towards not only do we want survival, we want survival with optimized cognitive and neural outcomes. So change can happen. and you can be the person who leads this change. And I'm going to give you an example of what happened at my organization. We actually had a case. It's a six day old term baby. Girl. Parents were shopping with her and mom suddenly noticed the babe was unresponsive and not breathing. Cpr was initiated by the police until E. M. S. Was able to arrive to the mall and they brought the patient to the closest emergency department. The baby was intubated and taken to the Nicu and started on a neonatal cooling protocol to 33°. The child was then child was then transported to our dorm Becker, pediatric ICU. So temperature management for H. I. E. In the neonatal who was just born is standard of care. And Nikki's they do this very well across the board and the standard of care and cognitive outcomes are better if you cool babies with H. I. E. When they've been born In this case, the child was six days old but was doing well. So the cooling protocol was initiated and there weren't any issues. She was doing great. So we continued it for 72 hours and we're using a cooling blanket. The bay remained intubated sedated and had continuous Eeg monitoring the challenge came with the rewarm. The reward was started by turning off the blanket and cooling blanket and starting to use the warmer. And it was very like try to turn this down. Try to turn this up. Oh that's too much turn this down and turn this down some more. And the child actually had a seizure at 36° and this could have happened regardless of how we were rewarming. This is a graph from our electronic health record of how the child's temperature appears to be managed. So the childhood was maintained at 33° and then appears to have been slowly re warmed over 27 hours to 36.2. What is not seen is what wasn't charted. And I know I'm sure that will never happen in your organization. But temperature actually vacillated between 32-33 or 37° over that 27 hours. Staff was using um non servo controlled methods to try to do a slow controlled rewarm. And it was highly labor intensive, more so than using a servo controlled method. And that slow controlled rewarm is vitally important for Children. So six months went by. The child survived and follow up. Mom says she's meeting her milestones. She's learning to swallow better. She hasn't had any seizures since that seizure that she had in the I. C. U. But staff really asked, you know can we do better. And a nurse asked me where I came from. We used a servo controlled t T. M. Machine. We didn't do this weird cooling blanket warmer thing. And so why are we using this Only for our cardiac arrest patients? Are we doing this right? Because we were really only using the servo controlled machine for our bigger pure cardiac arrest patients. When you know better you do better. How can we better manage temperature in the Picchu? Do we have a better method or equipment that we can use? And the answer was yes. So we started to approach this is how can we create a multidisciplinary pediatric T TM program to make sure we're not just saying that we're using normal author MIA or therapy or targeted temperature management. Um and just charting it but not actually doing it well. We assessed our current practice. We had collaborative education with staff. So physician and nursing staff because this is very multidisciplinary education was provided on temperature management systems that we had in our organization. If you have one be sure that whatever you have, you know how to use that equipment and use it? Well, we created a hospital policy, a protocol and a guideline. I created a pediatric targeted temperature management order set and all this aligned together and matched and then we did an assessment of our updated practice and this is a process that is continuing to occur on pds a cycles. We're always looking at like where is there lacks in knowledge maybe are we having trouble with our equipment. Um Is it a charting problem? Is it time to update any of these things? Has anything changed? Well overall we found there's potential challenges to a T. TM program. And one is the concept of counter warming which might reduce the incidents of shivering because really shivering with something that we have worked very very hard to do better for our patients who have targeted temperature management prescribed to them. So counter warming could reduce the incidence of shivering because it tricks the skins receptors into believing the body is warm. So to initiate counter warming warm areas used to circulate over the chest, arms and legs. And sometimes that seems counter to trying to cool or keep a patient from becoming federal. But the only time this becomes a problem is if you're using um for instance some sort of um Equipment where you can choose the temperature and you have a baby where you're using it and choosing 42 that can actually interfere with keeping the patient colder at your prescribed temperature. But for older toddlers and adolescents, this warm air tricks those skin receptors into thinking it's warmer than it is. And it's based on the same idea of using like we use a scarf or put on gloves when we walk out of our warm house into the cold outside air, it blunts that kind of feeling. So the other challenge was Pat confusion in our organization, our servo controlled temperature system uses past and it has weight ranges in it. So in pediatrics it's all about the weight, right? We always want to know first and foremost what's the weight because then we can intervene under any emergency situation if we know the weight pat selection however, can be challenging because it's all about the body surface area rather than the weight. The goal is to cover at least 40% of the patient's body surface area for efficient temperature control. So this was one of the educational areas that we had to really work on. The other is when a patient develops fever, the thermal regulatory set point can be reset. So when there's an elevated set point, the shiver threshold can also shift. So if we have someone with a normal temperature of say, 37 2 tents above that, the patient will naturally Vasil dilate to release heat Two tents below 37. The patient will vaso constrict one full degree below this, the patient will shiver. People have different natural resting body normal temperature. There have been also some studies actually challenging what is a normal temperature across the population. But for the most part, 37 is kind of normal 36-537. So when we try to set a goal of 36 sometimes that's where that shiver step point is and it can be very challenging. Using an objective method to assess bedside shivering is essential. The bedside shivering assessment scale is a tool that can help you evaluate shivering. The challenge with the B. S. A. S. Is to catch shivering and intervene early. So zero is no shivering. One is mild shivering and is localized to the neck or chest and this can be very subtle. So it actually requires laying hands on that neck and chest area and feeling for that subtle sometimes intermittent shivering. That can be. There. Two is shivering where you have the neck and the chest and extremity. Three is intermittent generalized shivering. So greater than two extremities and once you hit two and three um really bedside experienced people will say you don't have a lot of options other than paralytic to reset and try to stop that shivering and allow the servo controlled method that you're using to bring that temperature down if it starts to creep up. So shiver management is essential to A. T. T. M. Part of your bundle. The first line of therapy for shivering management is counter warming. Then we usually incorporate sedation and then finally paralytic agents can be used. Please be aware of precautions around paralytic agency. It can you won't be able to identify clinically significant seizures if your patient is muscle relaxed. Um So sometimes with sedation places will consider an anticonvulsant. Sedative continuous E. G. Depending on where you work is actually really important, especially if you have a muscle relaxed patient to make sure that subclinical seizures are not being missed. Subclinical seizures in our pediatric population is something that overall is actually occurring more than we probably um anticipate or realize and so E. G. Can be very important with this patient population. Drug metabolism can be impacted and appropriate. Dozing has to be really tailored to the specific conditions of that child and tightly monitored. So always remember to use your institutions guidelines when you are looking at optimizing shipper management. So challenges that often come up is higher rates of fever in those who have 37° as prescribed temperature. That delta between 37 and fever of 38 is small. And so it requires a lot closer monitoring to ensure that if your patient is producing heat um you're identifying why that is is it infection seizures or shivering or your three top things to think about right away. Um Sometimes organizations that have 36 5 and 37 or you know, patient populations that we choose 36 5, 37 have less aggressive management as far as shivering goes, Whether it's that they're not quite as sick and so you don't want fever but you don't want them to be without a clear neuro exam. Um It can be hard but if they're shivering they're gonna then easily have fever, increase that metabolic demand. So it can be very challenging. Um You're not able to use use the bedside of shiver assessment scale when um patient is relaxed but it's very important when the patient is not muscle relaxed and paralyzed, shiver, shiver prevention is really essential. And some of the challenges depending on you know what state you live in and the temperature in Oregon. It's typically cold here and so we're able to initiate and get to our gold temperature within six hours. Um If you're from a warmer area like florida for instance, you know, this can be challenging and needs to be higher on your list of things to make sure you initiate right away so that you're catching patients before they can become febrile. Oftentimes for us in Oregon patients who have had downtime are actually cold babies especially are very cold and we're almost doing a slow controlled rewarm too are prescribed temperature and once again, slow controlled rewarm, which requires a lot of active bedside monitoring of that child. We actually found other unanticipated uses for targeted temperature management. We've used it for Children found down from a drowning outdoors who come in incredibly cold. Um for a slow controlled rewarm, we've used it in refractory status epileptic Kosor patients post operatively with jet just bringing their temperature down to 35.5 avoided a Penta bark coma on one patient for example and kind of cooled the jets on the jet patient. Um So there are other uses for targeted temperature management outside of what we've discussed today. I wanted to share two stories with you. One is a three year old female who came in as a level one trauma. She had a nine millimeter gunshot wound to her head. Her GCS was three at the scene. She was intubated and taken to the nearest er. She was transported to our emergency department and went straight to the O. R. Her gunshot wound was by parietal and she had brain contents. Herning out her knee eating out of her exit sites. She was given antibiotics deodorant, hyper tonic saline mannitol and she was found to have an inter cranial sinus injury and cortical vessel injury as well. She bled a lot and had a massive transfusion protocol initiated in the operating room. A bolt was placed for I. C. P. Monitoring and she was brought to the pick you afterwards. This is the C. T. C. T. Of her head and you can see that there's a ballistic injury. There's an entry at the right parietal bone and exit at the left parietal bone, multi focal hemorrhages, hemorrhage into the ballistic tracked. She had sub arachnoid and epidural bleeds and small active venus hemorrhages that they found in the O. R. She had scalp hematomas at the entry and the exit site. So this is really tough because this is a child that we really didn't know if she would survive and if she survived what her outcomes could be targeted. Temperature management was prescribed for her at 36.5. Mostly because of her profuse bleeding. We actually maintained 36.5 and avoided fever on her for eight days in our Picchu. Her first fever was after that eight days of 38.5. This child did indeed survive and was able to leave our Picchu and be transferred to the ward. What was noted on the ward is that she cried with cares. She was nonverbal. She had minimal spontaneous eye opening. A left gaze preference, occasional upper extremity withdrawal to painful stimuli at this position. She was found that she had A. G. Two but she was able to P. O. Some foods. She preferred cheetos and chocolate. She smiled when her mother walked into the room. She actually laughed with pt and Ot therapies and she was able to bring her hand to her mouth. She was discharged to inpatient rehab. After that this was such an important case for us because this was a case where we looked back at our care and really felt that we did well for all the components for managing this child. It wasn't just a focus on sedation ventilator settings and sodium. We actually did all the components well including targeted temperature management which we all know is very labor intensive and the team did awesome. The last case I wanted to share is a patient she was she was 13 years old. She had a ruptured a VM that resulted in P. E. A arrest. She had complained of two days of headache before this she was found unresponsive at home. She was intubated immediately A. C. T. A. With inter cranial hemorrhage that was suspecting underlying a Vm. So arteriovenous malformation ruptured. She had a posterior fossa decompression immediately and bilateral dvds replaced. She had a P. E. A arrest in the O. R. Um Right when she actually as she came back to the pick you post O. R. She actually survived the Picchu and was transferred with products is most sympathetic hyperactivity, inability to follow commands to communicate or ambulance late. And this is someone we talked about having very very poor outcomes and we had told the family numerous times we didn't think that she would survive and she would probably die if she did survive. We didn't know what her survival outcomes would look like. Well on the ward. The P. T. Had a note that stated per mom patient has been a bit more alert with improved visual attention and occasionally responding to command for thumbs up Her mom. She can read mom wrote on paper if you can read this blink and saw the patient's eyes following along and then she blinked inconsistent and difficult to reproduce. This patient was discharged to a child care center with a trick and a G. Tube with a poor neurologic prognosis. One thing that I have learned over 14 years as a nurse practitioner in 20 years of taking care of Children is we're terrible at predicting outcomes. We don't have a crystal ball to tell us which Children are going to survive and which Children are going to survive with good outcomes versus poor outcomes. We do have a pediatric critical care and neuro trauma recovery program at our institution, one of two in the nation and it provides ongoing care and evaluation for Children that's focused on addressing physical and emotional symptoms after leaving the hospital, many Children have outcomes far better than what we see at transfer from the pick you. And so it's so important to ask ourselves, are we maximizing our therapies for everyone that 13 year old with the A. V. M. Is now walking, talking and going to school. She's working on headache management, sleep depression and repercussions of her pick you stay. So post intensive care syndrome issues and she does flourish on telling our team. See I didn't die. Touche my friend touche final thoughts I wanted to share with you is that T. T. M. Doesn't always mean hypothermia. We don't really know if it should right now. But if you're doing 33 degrees, I would say don't abandon it yet. T T. M. Is an important component to a post cardiac arrest bundle. It is a multidisciplinary intervention and it's not easy. T. T. M. Is safe in pediatrics and may result in better cognitive outcomes in those who do survive. And really that is the reason behind why I love talking about this topic is that it might improve outcomes in the Children that do survive. And I think that is incredibly important. My name is Serena kelly and this is my email. I'm happy to have any emails if there's anything that I might be able to do to help with your organization's program and management. Thank you for sharing your time with me. Thank you so much serena. Some of these questions kind of come up frequently. We're having these discussions. What do you do with shivering management if you don't have a protocol? Um right now, how can you start or prioritize? That is a great question of course, building consensus with providers and nursing at the bedside to develop a formal management is the best thing to do. But in the meantime, starting with counter warming is a simple, non invasive thing to do using like a bear hugger or something that puts warmth over the Torso, arms, legs of the patient for 2-3 minutes before initiating targeted temperature management. It's more important for patients who are warm and you want to bring their temperature down to blunt that shiver response. Um being in Oregon and colder states for instance, you might not need that because you're going to bring that temperature up to your gold temperature. But it's an important thing to do as practice. So everybody does the same thing every time. Counter warming, ensuring an opioid, ensuring magnesium for instance, can be used. Having a magnesium goal greater than four can actually really blunt that shiver response. And in some places they do magnesium infusions to keep that gold magnesium, we've had patients who have actually respond better to a magnesium dose than a couple of fentaNYL prs for instance to help blunt and stop that shivering. Of course paralytic is the last thing you want to pull out of your toolbox. Um because we always want to have a neuro exam but we also don't want shivering and fever. So that's kind of the last thing to do before um you know, before anything else, that's the last go to. We really want to get that shivering at that B. S. A. S. Of one if we can keep it at zero is like the big goal it can be done well. We definitely try to dress for the weather. I guess it's really important to dress for recovery to when we're managing and controlling the temperature. Absolutely. Another one of the topics that you talked about could be confusing for some of our listeners, we've heard about therapeutic hypothermia and then we've heard about targeted temperature management. Are they the same or how are they different? So targeted temperature management, If you go back into the literature, you know, there's therapeutic hypothermia, that was the old name. And as we really with the T TM one trial, we've moved away from therapeutic hypothermia and really focused on targeted temperature management. So regardless of 33 36 37 the goal is to have controlled targeted temperature management of a prescribed temperature. So, you know, even looking at literature, older literature will say normal author MIa and used 36 really that's still mild hypothermia. So, really digging into that literature and not just seeing what the words are, but looking at it and saying what is the temperature that you are speaking of? Give it a number when you're looking at the data instead of saying hypothermia because that has a lot of meaning. So we've moved away from therapeutic hypothermia to targeted temperature management. And it's our job as the team to attempt to prescribe the best temperature to treat that patient. So hypothermia being some of those deeper targets, locking someone in at a temperature or even controlling norma hermia. All points on that targeted temperature management continuum. Thank you so much.
