This recording was presented at the NTI, May 2021. Learn from Mary Kay Bader and Dr. Benjamin Abella, experts in the field of post resuscitation care who have treated hundreds of patients using targeted temperature management. They will cover evidence, review the practical side of bedside care, describe new trends and present case studies. (1 hour)
Welcome to this sunrise session. My name is Dr Benjamin Abella. I'm a faculty member at the University of pennsylvania. I'm an emergency medicine physician there but I also work very very closely with our critical care teams and many critical care nurses and physicians in the care of patients after cardiac arrest. And we're really pleased to bring you this session today. I'll be speaking with you along with a close friend and colleague mary Kay Bader, who also has been an accomplished educator, researcher and student of cardiac arrest care. Along with myself, our goal today will be to share with you the current state of the art of post cardiac arrest care and the use of a therapy called targeted temperature management or T. T. M. I'll be sharing with you first some of the scientific background of where we are currently with the therapy. And then um mary Kay is going to share with you some implementation uh and and more logistical issues pertaining to the therapy. So hopefully at the end of our session you will be better equipped to care for the next patient who comes in your doors with cardiac arrest, who gets their pulse back. So that's the plan. So to begin, I would like to start and end with clinical cases to keep it grounded in reality. So here's a fairly typical cardiac arrest scenario. You get a patient, She's a 57 year old woman who has cardiac arrest and prove the E. M. S. Per emergency medical services. She collapsed at home. Her husband was a witness. Now in this case we're fortunate he knew CPR and performed CPR apparently there were no pre arrest symptoms. So we really don't know exactly why this patient collapsed patient was found in ventricular fibrillation VF. And they were given a shock and they were brought to the emergency department. So this story should sound familiar to many of you have heard this story before in your critical care environments. Now, care continued in the emergency department and CPR was continued and eventually they got R. O. S. C. A return of spontaneous circulation that they got the pulse back and the patient is now comatose uh initial head cT is negative for trauma and initially CG does not reveal a stem. And as many of you know, an initial head ct in an initial E. C. G. Or two things on the key checklist within the first half an hour following cardiac arrest, you should get both of those things. In this case, they were both okay and the patient is now going to the medical iCU. So this vignette should be familiar to all of you as expert critical care providers. The question now, what do you do? What are you gonna do with this patient? Um and how are you going to best give them the best chance to have brain recovery and to leave the hospital walking and talking. And that's really the focus of this first presentation today. Yeah. So one of the key therapies to care for patients after cardiac arrest that has been developed over the last 15 to 20 years is this concept of post stress T TMR targeted temperature management. Now this used to be called therapeutic hypothermia or th and I'll explain a little bit why in a little while why the term T. T. M. Has supplanted th little confusion in the literature but the more correct term these days is T. T. M. So the notion of T. T. M. Is that when a patient comes in following cardiac arrest we lower their core body temperature, keep them cool for a while and then rewarm them. So this is a three stage process of cooling, keeping someone cool and then re warming them. And this generally starts in the emergency department, continues in the ICU setting for the first day or two of care and then patients are re warmed. The current understanding of this three phases of care is that you cool as quickly as you can. You keep people cool for about 24 hours and then you re warm them. But we'll get into some of these particulars during the course of the sunrise session. But first I just wanted to show you where these came from. Um some of you may know about these landmark trials. Some may not. This is the hack a study or the hypothermia. After cardiac arrest study. It was a trial than in Europe of patients after they got their pulse back from cardiac arrest where they were either cooled to 33°C and that's a typical target temperature. But we'll have much more on target temperature shortly. Right. They're cool to 33 or their randomized to no cooling and outcomes are assessed. This was another randomized trial published the same year out of Australia by Stephane Bernard and colleagues. Same idea, patients were randomised either to cooling to 33° or no cooling and then outcomes were assessed under the hypothesis that cooling would improve brain recovery and we don't have time to get into the path of physiology. But suffice it to say that after resuscitation cardiac arrest, there are many injuries that occur brain swelling, cell death of neurons, organ injury. And it's understood from animal studies That by cooling to 33, we can greatly improve these injury processes and greatly improve the chance of a good outcome. But it had not been put to the test clinically until these studies. And there was a third trial the year before that also briefly mentioned that also randomize people to cooling versus no. Cool. Well, what do these studies find? And this is sort of the summary here, both initially and then six months later. And you can see if you just look at the red percentages, a dramatic improvement in survival with cooling in all of these studies. And it's important to note that they only counted a success in these studies if patients had neurological recovery. So none of us, as critical care providers would consider a success of someone survives but is severely neurologically impaired. We care about the quality of survival. And so if they're in the red percentages, that means they had neurologic recovery. They were walking and talking. Um if you want to be technical about it, they had cerebral performance category CPC one or 2. And in all these studies there was a market improvement in the hack of study. They looked six months later and they found it was durable. So if you get people to leave the hospital walking and talking, they can do very well. And in fact at our hospital and others, we followed people for years after cardiac arrest. So I want to leave you with this general sense of optimism that if we as critical care providers can get people to that state, they can go back to life. They can live for years and and go back to their activities and their families. Now, what are the guidelines say about this as you know, every five years, the american Heart Association updates of the resuscitation guidelines. Um and and in the 2020 guidelines, the news version that came out this last year essentially, they remained intact with regard to recommendations for T. T. M. So what they say is if you get someone back from cardiac arrest and they're not waking up, that is they're not. And to define that precisely there Glasgow motor scores not six, they're not following commands appropriately. If that's the case, they need T. T. M. To try to mitigate brain injury and improve recovery. And the guidelines recommend this for any rhythm. It used to be felt that patients with shock kable arrest rhythms did better with this. But it turns out that any rhythm of arrest would benefit and we'll get to that a little bit later. Um Why that's the case now. It's important that we spend a few minutes on this study. This study has caused a lot of confusion in the literature. This is known as the T. T. M. Trial and this was by Nicholas Nielsen and colleagues in Scandinavia. They looked at a dose question, the dose of T. T. M. And so you can think about the degree of temperature depression as a dose. And so initially and and many households we have been cooling people to 33 Celsius. These guys asked the question um would it is it necessary to Coulter 33 or can we do T. T. M. 2 36 degrees, which is a milder degree of uh temperature control in theory, a mild or therapy. And could we get the same benefit? And the reason why they thought this was after cardiac arrest, The brain stem is dysfunctional. And many people get these things called neurogenesis fevers. They get really high fevers that they're not from infection, it's just from the brain acting abnormally. And these fevers are bad. And so these investigators said, well, cooling to 33 improves outcomes. Great. But maybe the benefit is not so much from cooling, but from aggressive fever avoidance. Whatever device you want to use, um, if you, if you do it at 33 or you do it at 36 maybe You get the benefit of fever avoidance in either case. Well, that's sort of what they found. And this is the Kaplan meier plot. They found the exact same survival when they manage patients that are 33 or 36. This was very surprising because decades of animal work has shown that the deeper you cool, the better the outcome in animals. But this was suggesting that might not be the case in people. So what's going on here and to sort of summarize the key question raised by this trial here are the results from the hacker trial. I showed you these. I'm just in a table but here it is in graphic format. Here's the results from the Bernard trial. Both of these studies showed big improvements in survival with cooling in here are the results in this new TPM trial where at 33 or 36 they found fairly similar outcomes. So what gives how can you get such different results with the same therapy and the same patients? And the important thing to know about this T. T. M. Trial is the control group is different. So in the heck and Bernard trial there was no temperature control and the control groups. So if people got fevers they got fevers now they might treat the fever. But it was too late to treat it sometimes in the T. TM group. The study by definition patients where they are locked in a. 33 or locked in at 36. So they are very different kinds of studies. And to show you this graphically here are the two temperature curves and you can see and I've made the Y axis the same on the left. You have the Nielsen study on the radio of the hack of study and you in the Bernard study and I won't show you the graph. I'll just tell you What you can see is the control groups were very different by design the TPM trial, the control group is 36. The hacker study By not designed just because they didn't control the temperature. Many patients had higher temperatures and this 1.6° difference on average is actually a lot when you're talking about injured brains and brain physiology. So the studies are different and and if if you didn't exactly follow this, I'm gonna leave you with the following, take home message from from this study. The T. T. M. Trial did not test whether T. T. M. Worked or not. It did not re evaluate the same question as heck. And Bernard and this is important to state really clearly because many people have gotten this confused. The TPM trial did not say T. T. M. Doesn't work. It just says that T. T. M. Could work at 33 or it could work at 36. And and they may be equivalent. But many hospitals interpreted this trial to say, oh we shouldn't do t tm because there was no difference between the two arms, but it's an apples to oranges comparison. So don't fall into that trap 36° is still active temperature management. And they used active management to improve outcomes in that trial. So what have we done at Penn and what many other hospitals done with this trial? We have maintained that if you get someone after cardiac arrest, the default gold temperature should be 33 Celsius. And we do that because in the T. T. M. Trial there was no benefit or harm at either temperature. It was awash. There were several trials before it that showed 33 was good. And there's all this animal literature showing 33 is good. So we said, you know what, one negative study is not going to change our practice. We target 33 fall in cardiac arrest. However, in some situations for some patients, we might choose up to 36 because the T. T. M. Trial supports that. Uh if there's an individual risk benefit different. So for example, for example, we believe that when you cool to 33 it may increase the risk of bleeding a little bit, not a lot but a little. So if we get a cardiac arrest patient who had a P. E. A arrest from bleeding from a Gi bleed, That individual patient, the risk benefit ratio is different than the VF patient. And we say well if they died from bleeding, maybe we should just maintain them at 36 because the risk of bleeding is high enough in this patient than 33 might be dangerous. Now this is the art of medicine, there's no science supporting that premise, but the notion being that we, as clinicians, can now decide and make individual risk benefit assessments. Okay? So what have others done? Well, a survey was done to look around other hospitals and this was done in Europe to ask what did they do? And it was found in the intensive care units of Europe. Most physicians stuck to their guns and and maintain 33 is the gold target temperature. But some switch to 36. And that created an interesting experiment. The hospitals have switched. How did it work out for them? Well, um, interesting news and worrisome news. The hospitals that switched their outcomes worsened. This is one example. There are several I could show you, but in the interest of time, this is one example where this hospital in Australia switch to 36. Their outcomes got worse, their travel got worse. They said poopsie and they switch back to 33. There are examples of this from the United States as well, that hospitals have switched outcomes worse, they switched back. So this made us feel better about sticking with 33. And I would recommend to you at this point I'm 33 is is an ideal goal temperature. Now I promised I talk about the initial rhythms and this trial is an important one. Came out more recently looking at 33 versus 37 for post arrest patients with non shock kable rhythms. So if you ever wondered why the 2020 guidelines say cool regardless of the initial arrest rhythm, this study is the reason why. So this was a 25 iCU study in France a randomized trial where patients after P. A. Racist italy were manager there 33 or 37. Um here's their temperature curves if you're interested in such things. Um Most importantly here's who they enrolled and you can readily see that most of the patients had initial arrest rhythms of asystole your P. A. So these patients are sick, they do much worse than shock double rhythm arrest patients in general. But nonetheless despite that fact they found an improvement and outcome with cooling. So you see here the bottom line um CPC score of one or two. That means neurologically a favorable recovery was much higher in the cool group of this non cool group. So this is very good news for us as clinical providers. As you know, it's sometimes pretty hard to figure out what the initial arrest rhythm was. The M. S. Records are incomplete. There's a lot of confusion in the field. Now we don't need to know. I mean we'd like to know but as far as cooling decisions are concerned we don't need to know if the patient had a cardiac arrest. If they're not waking up it could be P. A. System. Even if it doesn't matter they need cooling. And it's supported now by this randomized controlled trial. In addition to the trials that I showed you before now, an important question for us as critical care providers is the timing. How soon do we have to start this therapy? I get asked that question quite a bit. The general understanding has always been, you should start this therapy as soon as possible but there was not a lot of evidence to support that but this is one of the bigger and better studies that does support that concept. So they looked in a very large cohort of patients who got cooled and just in the real world experience, this wasn't a randomized trial. And on the left here you see a hissed a gram just showing when people got cooled this was the door to T. T. M. Initiation time, you know like door to balloon time first Emmy. This is door to cooling. Start time. And as you might expect in the real world, there's a variety of start time. Some people got killed right away. Some people it took longer. So then they got to ask the question didn't matter. And on the right you can see some statistics but I'll just tell you verbally it mattered. So the sooner people got cooled the better the outcome and it mattered hour by hour. So the general understanding out of this paper was you really want to get cooling started within two hours following cardiac arrest. Now if you can't get started in two hours it happens. Maybe the patient's unstable. Maybe there's other things going on. But ideally you would get the cooling started within two hours. And what that means practically is cooling should probably start in the E. R. Or an E. D. So so if you're ready colleagues are saying oh you know we're going to get a bed and go upstairs you can cool upstairs. I might suggest that you push back on them and say you know if the bed's not immediately available you really need to start in the er because if we wait three or four hours we lose some of the benefit that the patient might get from this therapy. So so this paper supports cooling as soon as possible, preferably in the emergency department now um really cooling as part of a bundle and there's other aspects to the bundle of care. This is work from our hospital where way back when we took T. T. M. We combined it with early and aggressive cardiac cath for some patients For select patients. We combined it with mean arterial pressure goals. And many of you may have in your protocols you can go check after after you get After this lecture. Most hospitals have a protocol that stipulates 65 mm of mercury as a goal. Mean arterial pressure. We put that into our protocol early on. And and so this bundle of care approach, we saw that we could greatly improve survival following cardiac arrest. So this was exciting. And it was sort of one of the earlier demonstrations of the bundle of care approach fall in cardiac arrest. Well, there are many things that might go into this bundle and we could build a whole course. Indeed. We have and I'll tell you about the course a little bit later, um, too much to share in a short sunrise session. But these are some examples of the menu if you will of some of the things that are important to include or at least consider when taking care of people after cardiac arrest. We'll just touch on a couple of these just as examples. And one of them is what we like to call post T. T. M. Norma hermia and what is the idea here? Well, um, it turns out that when you cool people, you keep them cool and you? Re warm them, you're not out of the woods. Um, the neurasthenic fevers can still strike and we found, and this is work from our group and also from some others in Pittsburgh, we found that many people still got Parex E. A. That is elevated temperatures after teach him and rewarming The brain stem was so dysfunctional. They still spiked. And when we looked at the higher versus lower temperature elevations, the higher the temperature, the worst they did. So these fevers are bad. So it speaks to a fairly easy solution. When we cool and rewarm, we leave the cooling device in place and we do therapeutic norma thermal for 24 hours. So we just keep the keep the cooling going but not cooling. The normal for me going the temperature management going for another 24 hours. And we think that's easy to do and it may very well improve outcomes. That's one example of thinking beyond just initial T. T. M. Now, another example that is worth talking about about this bundle of care is the role of the cardiac cath lab. I again asked all the time. Dr bell, what do we do, do we catch all these patients to catch some of these patients? So the bottom line answer is we don't yet know but I wanted to share with you just some of the current evidence around this. And so um we looked at this and other groups have tried to to say can we predict, can we tell who needs the Cath lab after arrest If it's not a stem me after all, you know that if the stem you go to the lab, if it's not a steamy, what do you do? And we found it was really hard to tell basically if they were older. Um if they had a shock double rhythm, if they had a history of coronary disease, they were more likely to require cath, but it wasn't perfect and and the initial troponin was kind of useless. It turns out the initially cG surprisingly, it was kind of useless. So it's pretty hard to know who should go to the catholic or not. We're trying to study that as we speak. The other question of course is when do they need the lab? And that's also not clear. This was a study called the co act trial that is now the darling of cardiologists around the world. And I'll tell you why in a second, they looked at immediate cath versus delayed cath fall in cardiac arrest. This was done in holland and they found that the survival was the same. If you Catherine terry kath later. Now cardiologists love this because basically the study said they could stay in bed. They don't need to catch people at two in the morning. They can wait several days to catch people and the outcomes of the same. But this is not the final word. So don't don't take all these studies at face value. When you read the data deeply in the study, this is in holland and holland. They have excellent cardiac care. Um Everybody was on A Staten, everybody was on aspirin. It turns out the great majority of people did not need PC. I they didn't get a balloon. They didn't get a stent. So the early versus late isn't exactly fair. It's not the angiography that saves lives. It's the balloon or stent. And so I don't think this is the final answer to the question. And we need to do more research on who to cath and when to cath fall in cardiac arrest. Because we do know that's some cardiac arrest out of hospital are from acute coronary lesions, acute coronary syndrome, I should say. And therefore cath may benefit some patients. So I don't have answers on that one. But I thought I'd share with you a flavor of where the literature currently is at now. Another key issue, of course is prognostication and this is very important for all of us. As critical care providers. We looked at this and found that patients take time to recover from cardiac arrest. And this is looking at when people wake up waking up, took 34 or five days following cardiac arrest. So we always tell Providers tell the families, look, this is a marathon, not a sprint. It may take days to know whether your loved one is going to wake up or not. And in fact, this has now entered the guidelines. This has persisted into the new guidelines. But I show you here in 2015, the guidelines say do not use the bedside exam To make decisions about withdrawal of care for at least 72 hours. If not longer. That is to say you need to you need to wait because patients may be comatose. They may not be responsive for quite some time. Um, uh and and and so therefore you need to wait and and in fact you may need to wait for five days before their pupils start to respond before they start to wake up and so on and so forth. Yeah. Now one question that comes up also is um pre hospital T. T. M if cooling is so important, should we do in the ambulance? I'll quickly just tell, you know, you shouldn't. A number of studies have looked at this and found that there's no benefit from cooling in the ambulance before you get to the hospital. So this is truly an emergency department and I see you based intervention in current times. And so in summary, T. T. M. Is an important part of this. But there's also considerations for Cath for him. Oh dynamics for avoiding early withdrawal. So that in theory, we can get more survivors. Like the woman here in the Black Blazer who was a cardiac arrest patient we treated some years ago and we like to celebrate our survivors and have little ceremonies. This was a little event we had with one of the nurses who is very involved in her care. And it was a very sort of happy story and we like these happy stories and hopefully I can inspire you to have your own happy stories at your hospitals. And so um to educate more on this topic, we created something called the Pentium Academy because we recognize this is a lot of content and it's hard to do this justice and just a one session. And and so there's a gap between what we know and on the left here you see there's good studies, there's good technologies on the right, the variability and care. And so you can use that QR code or follow us on twitter and find our website. We have podcasts, um we do a twice year conference um and we have other materials available as well to help you and help folks improve their care for patients after cardiac arrest. And in fact we just did a course in March. We're going to do another one in september stay tuned. There's our our website where we do a day long symposium where we discuss everything around post arrest care. And with that I'll stop and turn it over to my colleague, mary Kay Bader who will continue this conversation around how to better care for patients after cardiac arrest mary Kay, thank you Ben. My name is mary Kay Bader. I'm the neuro critical Care Clinical Nurse specialist at providence Mission Hospital in mission California. I'm happy to share with you any protocols that you would like just email me and I will show them. Yeah. My disclosures are listed on this slide. Uh And you can also see them at the A. C. N. Website since Ben talked about the research that has been traded in the field of T. T. M. Specifically in post cardiac arrest. I'm going to concentrate on a research review that looks at how we protocol is care and how specifically with targeted temperature management. What the impact having a protocol in a system of care developed in place in your institution can make a difference in patient outcomes. So what is the evidence to support interventions or bundling? And why should we have a bundle? Well, years ago, the Institute of Health Care Improvement supported the use of evidence based interventions for a specific population and care environment and found that it has a synergistic effect on patient outcomes. For example, something that critical care nurses are very familiar with is the icy liberation bundle that has been shown to have a dose related effect. The more elements completed has been associated with improve patient outcomes. Complete bundle performance was associated with better outcomes. So Bundling elicits a team based approach. Bondo keeps the patient needs with small continuous changes so your ability to individualize a bundle should occur in clinical practice. So let's take a look at T. T. M. Bundle evidence. So what are we dealing with when a person has an out of cardiac arrest and their heart stops? There's a lack of profusion to the brain. This result a systemic ischemia, we profusion injury to the brain and to the body. A hypoxic brain injury. Myocardial dysfunction, especially if a steamy was involved, an unknown underlying ideology. Cardiac arrest carries a very high mortality and a risk for permanent neurological injury. The syndrome called post cardiac arrest syndrome, or P. C. A. S. Is an inflammatory state resulting from an ischemia, re profusion impact injury impacting multiple organ systems. The care of these patients include multiple disciplines cardiology, critical care, emergency department neurology. We have nursing pharmacy respiratory, so multi disciplines involved in caring for this patient population interventions that can reduce the impact of PCS include coronary interventions, targeted temperature management and optimizing profusion to the major body systems. Organs. The interventions, though, are complex. They require inform practitioners and they may have competing priorities creating a structured pathway or protocol, integrating these multiple complex interventions in a timely manner may have benefit in managing this complex patient population. So let's take a look at the evidence. There are enough studies that have looked at Bundling care in post cardiac arrest in 2019. There was a meta analysis of six studies involving 1422 patients. They looked at interventions in the care pathway, including early coronary angiography, at a temperature management class management. The I. C. U. The meta analysis found significantly higher odds of achieved favorable outcome in patients treated in a structured care pathway. When compared standard care 1018 the Hanover cardiac resuscitation algorithm and standardized protocol looked at was a single center observation. I'll study looking at the impact of using this multidisciplinary approach with rapid screening in the emergency department, a structured diagnostic approach, echo cT coronary angiography, hemo, dynamic stabilization and therapeutic hypothermia. The results showed a markedly lower 30 day mortality 27% compared with the published trial of 44%. Another study published in 2017. This was done in china was the early standardized treatment program for P. A. C. S. The study investigated weaknesses in the implementation of the protocol is a multi center retrospective cohort. The protocol included ICU management of him. Oh dynamics, oxygenation, ventilation and T. T. M. With interventions and phase goals. Results showed that 52 patients, 92% of them had S. P. 02 to the treatment standards, 67% hit the math target, 29% hit glucose control and 19 had therapeutic hypothermia targets. Another study in 2016 was done in the United Kingdom and it looked at the management of cardiac arrest survivors. They found that treatment protocols we used in 87% of the 172 units emergency cardiac service available 24 7 in 26% of these centers And later bunk was used in 94% of the units and ATT M. Protocol in 90%. In 2011 there was a study at one centre looked at a care bundle. It included T. T. M. And early mode dynamic optimization for cause patients with return of spontaneous circulation out in out of hospital cardiac arrest. The elements are list slot therapeutic hypothermia CVP, or central venous oxygen saturation monitoring within two hours, targeted temperature management in four hours CVP greater than 12 and six hours a map greater than 65 hours. Central venous oxygen saturation greater. So the therapeutic hypothermia had to be maintained for 24 hours. And they also noted a one to look at a decrease in lactaid in at the 24 hour mark. There were 55 patients in this study, 26 pre bundle and 29 post bundle in hospital mortality in the bundle compared with pre bundled patients was 55% versus 69% in the bundle patients. Those patients who received all elements of care had an immortality of 33% compared with 60.9% and those receiving only some of the bundle elements and that these bundle patients tended to achieve good neurological outcome compared with pre bundled patients. A retrospective study done at Pittsburgh in 2008 and published developed a standardized treatment protocol for post cardiac arrest survivors. And it included TTM bundles of care including human dynamics, glucose, cardiac catheterization. And they looked at 135 patients from out of hospital cardiac arrest and 106 within hospital rest. The comatose patients with beef in the attack related out of hospital cardiac was more likely to achieve a good outcome with therapeutic hypothermia treatment plan than without it. And this is the series of system enhancements. They found improved neurologic the outcome after cardiac arrest, so increasing the use of therapeutic hypothermia, early cardiac catheterization. But they emphasized it required a multidisciplinary approach. In 2000 and six, a study published by uh sunday at all from Norway looked at out of hospital cardiac arrest survivors that were admitted to the ICU from 2, 2000 and fly. And then included in a prospective observational study from uh That were included undergoing T. T. M. and they compared that to controls from 1996 to 1998. The standardized treatment protocol included T. T. M. Early coronary intervention and standardized goals for glucose, thermodynamics, ventilation and the management of seizures. The results sought found that significantly more patients survived to discharge with a favorable outcome in the intervention period of TT MPC I. And standardized goals than those in the control period from years before. And this was the article that was published in resuscitation. So implementing these bundle elements significantly improved outcomes in their patient populations that they looked at. Now there are a number of review articles and it's really beyond the time to spend go in depth in a number of these articles. But what they're doing is making recommendations so that when you're looking to build a bundle, some bundles can be built based on the hours post cardiac arrest, 0 to 2 hours. What about 2 to 96 hours and then greater than 96 hours. So this particular review article by Walters emphasised periods of time and how we need to implement certain things based on the time post cardiac arrest. Um they all another study found minimizing delays in the initiation of induced hypothermia irrespective of the cardiac arrest location. They recommend create cross disciplinary and consensus based treatment algorithm and using this common treatment algorithm in the entire hospital two stamps care. There was another review article by robert, also using an algorithm to identify comatose resuscitated patients for emergent coronary angiography and the early use of T. T. M. Best practice statement using a goal directed approach. So once again, you see a number of elements that I've mentioned in previous bundles that are put together um to identify a cohesive bundle to deliver care to T. T. M. Patients. Um Other review articles matter and Reynolds recommended a series of algorithms and list to manage the four major complications of post A. CS. So uh the goal is to minimize secondary brain injury. How do you do that with T. T. M. Coronary revascularization? How do you do it get them to the cath lab if they are relative hypertension versus having the patient too low or too high with their blood pressure, so directing a target at blood pressure at oxygenation. Using egg monitor to look for seizures and managing glucose and electrolytes. Now here was a study or a review article that actually recommended pathways to include three steps based on time field to the E. D. To cath lab to ICU. So breaking down the elements of time based on where the patient was moving from the field to the E. D. To the cath lab to the ICU. And so they're bundle for post arrest included T. T. M. Early coronary angiography and general supportive measures. So as I looked through all the review articles as well as the articles published on outcomes using different bundle elements, you can come up with what the bundle elements should be, what interventions need to be described during that period and what parameters bedside parameters you would use. So I encourage you to take a look at this uh slide oxygenation, ventilation, hemo dynamic optimization, T. T. M. Early cardiac catheterization, urologic care, seizure surveillance and management and metabolic arrangements. And hopefully this will give you some ideas on how to structure your own protocol with bundles. So what's the role of the ICU nurse? What are the practical aspects of treating the post cardiac arrest patient? And we know from the 2020 american heart association guidelines as well as european guidelines. There are recommendations on implementing T. T. M. There are recommendations on how we should manage the patient to monitor for seizures, et cetera. So, having a protocol that includes inclusion and exclusion criteria, Gordon's and then making sure that as you build the protocol you address those phases of care. So in the emergency department that the physician will assess the patient for appropriateness of treatment, contact the intensive ists, Look at inclusion and exclusion criteria and then uh also consult with cardiology neurology, possibly doing a ct before they go to the cath lab. Sometimes patients have a cardiac arrest that has been caused by an aneurysm rupture in the brain. Those patients come in they can present with cardiac arrest. And if you take that patient to the Cath lab because maybe they're showing steamy like signs. Taco soup oh syndrome or myocardial stunning. Which is a common uh thing that can happen in a subarachnoid hemorrhage rupture is that you could find a brain that's full of blood and you would not want to give that patient heparin in a cath lab. So considering should this patient go to C. T. Prior to the Cath lab and then uh making sure you have your priorities, ventilation management, non invasive and invasive blood pressure monitoring. Making sure you have your hemo dynamic arterial pressure, cardiac output device C. D. Pp. A Lion's foley or sofa Jill catheters with temperature probes and some type of external or internal cooling device. This is a slide that I put together that looks at protocol induction. So what are the priorities based on what I shared on the bundle elements that you want to do when the patient is just being induced? So under oxygenation, ventilation of meds, intubation, mechanical ventilation, optimizing oxygenation and CO. Two. Making sure your sedation analgesic agents are on board. That you have assessed the level of sedation as well as assessed in the presence of shivering and then prior to the induction of T. T. M. Policing the patient with a paralytic, monitoring the bedside shivering assessment, score Trina four and then also paying attention to these other elements hemo dynamics monitoring egg. Do you have an arterial line to look at blood pressure? Do you have some type of hemo dynamic monitor and establishing a goal for your map cardiac catheterization and time to vessel opening. T. Tm induction temp priorities. So making sure that maybe we're going to use ice saline for this patient. Maybe not. Depending on what type of stem me or my cardio event they had Some patients can tolerate to leaders of ice sailing. Some patients can only tolerate 500 CCS. Maybe they don't get any ice saline bolus monitoring attempt continuously in a reliable source. So either the esophagus or in the bladder and conducting your bedside shivering assessment score every 15 minutes during induction. You want neuro and seizure control. So monitoring the neuro status pupils, we use the pupil diameter device that helps us quantify people are reaction E. G. Getting a rapid response E. G. On your patient as soon as possible and then treating the patient for any kind of seizure activity And then metabolism, monitoring the labs the electrolytes, looking at the glucose and watching your patient during that time period. So this is a slide that shows during hack induction the frequency of your vital signs. And they're monitoring parameters for every 15 minutes every two hours in every four hours. Now, once the patient hits target and ideally you want to be to target within 2 to 4 hours, the faster you get to target, the better the outcome that patients going to have. So patients mike Mooney Dr Mooney did a study that was published way back in 2011 in circulation that found that every hour we delayed starting hypothermia and getting the patient to target temperature. There was a 20% increase in mortality. So this is not something you wait eight hours later when they arrived in your ice you. This needs to be started immediately in the emergency department. So once your patients now in the ice you, they've hit their target temperature whether it's 33 or 36 whatever it is, then again through your bundles, oxygen bent and meds, hemo dynamics, blood pressure map rhythm, T. T. M. Your 10 priorities, neuro seizure control and metabolism monitoring your labs. Remember when patients are at maintenance and if they're down at 33 the shifting of the electrolytes cause the potassium levels to go down the mag levels of phosphorus levels but do not over correct them during maintenance. Because when you re warn the patient, those electrolytes have been a shift again. This is a graphic slide that shows how frequently the parameters should be assessed every hour, six hours and eight hours when you're in the maintenance phase. Now in the rewarm phase. This is when 24 hours of cooling has been completed, we're going to set the rewarm perhaps 0.25°F. Maybe you're going to do it a little slower but really shouldn't be any faster than that. And once again, when you re warm. These when this is when the patient's phase or dilate so their blood pressure is going to drop. This is where their glucose levels can drop, especially if they're on an insulin drip. Should be very careful. Pay attention to your electrolytes. Pay attention to the glucose. Watch the different parameters such as the You're looking for your neuro parameters. You're looking at the parameters on the machine. You're looking at your cardiac chemo dynamic parameters as well as your oxygenation and ventilation. Now during rewarm at our facility, we recommend that once you're at target and your rewarming, then you you reassess this patient every 30 minutes. There's a lot that changes during re warm. To me. Rewarming is the most unstable time. So you have to be very careful and vigilant during this phase and then once they get back to 37°, you don't want your patient to have a rebound fever. So keeping them normal thermic is very, very important. These recommendations, which appeared in the 2020 guidelines, the American Heart Association emphasis that the prevention and treatment of fever occur for at least 72 hours after the patients return of spontaneous circulation. So very very important to keep that patient in the normal thermic range. And so you'll need a protocol that addresses normal ther mia. So how you assess the patient, how often you assess them where you're measuring the temperature. If the temperature develops a fever. Do you have a protocol that says, I'm going to give ideas acetaminophen, erectile, acetaminophen, I'm going to be um maybe the temperature has gone up and they need an ice fluid challenge and um we do that 20 C uh typically 10 to 20 cc's per kilo over 30 to 45 minutes. But once again, if you have a cardiac patient, especially one that's prone to failure, you may not be able to use ice sailing as a means to bring the temperature down and what if that temperature still won't come? It's refractory, it's greater than 38 degrees. Well then you're going to use some kind of device right to help you bring that temperature down. Make sure you have a temperature probe must be in the patient to provide a continuous feedback loop as you're trying to bring the temperatures down now, monitor the bedside shivering assessment score and have your anti shivering protocol handy. Hopefully the physicians already put in the orders so that you can stop the shivering if they're just at a. B. S. A. S. Of one. By the time you wait 23 it's too late. So let's take a look just to bring this to closure an admission of a sudden cardiac arrest or a T. T. M. Case. So this is a 51 year old female who had a medical history of GERD patient was eating breakfast, suddenly clutched her chest and collapsed in front of her husband. Paramedics were called began cpr. The paramedics arrived V fib they defib related times. One E. K. G. In the field showed S. T. Elevation and they arrived 13 oh three was a code blue 13 oh seven code stem activated from the field. So they came into the emergency department. The initial 12 levy kg. Well if you look very carefully show U. S. T. Elevation in V. Two, V. Three, B. Four and B. Five. You have leads one in A. V. L. Also impacted as well as reciprocal changes, esti depression and leads three and a BF. So in the emergency department they arrived at 13 12 vital signs. Heart rate was 74. Blood pressure's 1, 17/83 reps or 18 temperatures 98.6. Uh The patient's agitated, nonverbal. They're not falling commands. GCS is seven. So the patient is intubated. There was some evidence of pulmonary oedema. So right, this is not a patient. We're gonna wanna give I sailing too. And they're going to go to C. T. And then the Cath lab. So if you take a look at their chemistries in the emergency department, you can see the sodium potassium chloride ceo. To ionized calcium, creatinine, glucose, glucose is a little bit elevated. You can see the rest of the parameters that were measured via istat. The proponents, you can see the serial proponents that were obtained on this patient indicative of something going on in the heart. So she underwent a trans thoracic echocardiogram, the ejection fraction of 36%. Um Also they demonstrated mid to distal anterior septal wall and apex, a kinesis. And so when you look at the left main and the left anterior descending, there was 100% occlusion of the proximal lady. And so this is not a good situation to be in. You want to be in a cath lab when you have something like that. This is after the placement of a drug eluting stent to the proximal led. Before I forget. I want to thank Theresa Wavre for her sharing this case study from the cardiac unit. Now at 15 25 patient arrives to the critical care from the cath lab. She's on propofol. The beauty mean and deodorant, kong googler. And the ice sailing was initiating critical care. Now that is one of those things that the physicians have to discuss whether they think they she could tolerate having that fluid bolus, she was also on fentaNYL and they started a paralytic drip on her. The machine cooling started at 1605. They were able to reach target 33° at 1800. And um this diagram down here shows you the pupil ammeter, which N. P. I. Is anytime. There's anything under three that is abnormal. And the millimeters per second Construction velocity shows very slow sluggish pupils. Now at 1830, this is uh in sea ice. You she started on mill reknown. She's on norepinephrine, you can see the patient's temperature. She did a little overshoot there. uh this is during her maintenance phase. On February 15 she had some increasing human dynamic instability. They increased the mill unknown, increased in europe. She had a bronchoscopy for aspiration. And uh then you follow Milliner brought back down. She got some dextrose for low blood glucose. Mylan on was discontinued at 1600. Rewarming was started here at 1800 at 18000.15 degrees per hour. And at 22:39 they added final effort. Not unusual to see a base oppressor uh added during reward because of the Vaso dilation. At one o'clock they added basil present at 10 o'clock. The cardiac cns was rounding the patients on multiple drips, urine output was dropping and the patient was in cardiogenic shock. So they contacted the intensive ist discussed the shock algorithm for Detroit recommended use of a partial circulatory system. Vice, that was inserted at 1500 with a flow rate of 3.6 L per minute. She completed her rewarm the next day 24 hours later uh 1900 days. Oh active drips that we're going we're debuting and norepinephrine. They added Fennel Ephron. So day 42 day six she was maintained on multiple viso active drips. They started to win those slowly. On day seven the impeller was discontinued nitroglycerin and debuted. I mean we're tight traded off. She was excavated on day 10 she was transferred to the cardiac telemetry unit And discharged home on day 13 alert and oriented following commands neurologically intact. Week but five out of five with extremely so she had an extraordinary outcome. And I believe that this outcome was only attained because of the cooperation between the different disciplines and the aggressive approach with T. T. M. Cardiac uh cardiac cath and stabilization of what was going on in her heart and then her systems support during T. T. M. Well, hopefully you had an opportunity to ask some questions in the chat box during this presentation, but we are happy to answer any questions. Just email either one of us, dr Bennett Bella or me. Thank you.
