Ομάδα Εργασίας Καρδιοπνευμονικής Αναζωογόνησης

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Ἀλαλά Γιάνναρης
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1 Ομάδα Εργασίας Καρδιοπνευμονικής Αναζωογόνησης Λουτράκι 19/02/2010 ΘΕΡΑΠΕΥΤΙΚΗ ΥΠΟΘΕΡΜΙΑ ΕΝ ΕΙΞΕΙΣ ΕΝΑΡΞΗ ΚΑΙ ΧΡΟΝΙΚΗ ΙΑΡΚΕΙΑ ΜΕΘΟ ΟΙ Αθανάσιος Μαρινάκος Καρδιολογική Κλινική Κωνσταντοπούλειου Νοσοκομείου Νέας Ιωνίας

2 Present Prehospital Cardiac Arrest Outcomes 50% No ROSC 25% Die in Hospital 10% Brain Damage 25% Leave the Hospital 15% Good Outcome

3 THERAPEUTIC HYPOTHERMIA Inducing mild therapeutic hypothermia in selected patients surviving out-of-hospital sudden cardiac arrest has a major impact on long-term neurologically intact survival and may prove to be one of the most important clinical advancements in the science of resuscitation. Hypothermia represents a better neuroprotectant following a blockage of blood flow to the brain than any known drug.

4 THERAPEUTIC HYPOTHERMIA Hypothermia Definition - a condition in which an organism's temperature drops below that required for normal metabolism and body functions. Subdivided into four different degrees: Mild (32-35ºC or 90-95ºF) Moderate (28-32ºC or ºF ) Severe (20-28ºC or ºF) Profound ( < 20ºC or < 68ºF)

5 THERAPEUTIC HYPOTHERMIA Therapeutic hypothermia: Controlled induced hypothermia (potentially deleterious effects being controlled or suppressed) C Ισορροπία μεταξύ κλινικού αποτελέσματος και καρδιαγγειακής τοξικότητας θ<31 0 C -Slow AF θ<28 0 C- VF

6 Ιστορική αναδρομή της Θεραπευτικής υποθερμίας Ιπποκράτης 450 πχ Baron Larrey, 1814 χειρουργός του Ναπολέοντα

7 Ιστορική αναδρομή της Θεραπευτικής υποθερμίας Πρώτες μελέτες πριν 50 χρόνια Κύριοι λόγοι εγκατάλειψης: ανεπιθύμητες ενέργειες & αβέβαια αποτελέσματα Anesth.Analg Πειραματικές μελέτες 3 Κλινικές μελέτες το (ΝΕJM ) Συστάσεις από 2003

8 ΜΕΤΑ ΚΑΡΔΙΟΑΝΑΠΝΕΥΣΤΙΚΗ ΑΝΑΚΟΠΗ

9 ΜΕΤΑ ΚΑΡΔΙΟΑΝΑΠΝΕΥΣΤΙΚΗ ΑΝΑΚΟΠΗ European Study: HACA patients randomized to hypothermia or normothermia - Cooling Methods: Cool mattress and tent (KCI) - Favorable neurologic outcome and overall mortality within 6 months Results: Hypothermia Normothermia Good Outcome 55% 39% Mortality 41% 55% Australian Study - 77 patients randomized - Cooling Method: Ice packs (0.9 C/hr) - Survival to hospital discharge with sufficiently good neurologic function to be sent home or to a rehabilitation facility Results: Hypothermia Normothermia Good Outcome 49% 26% Mortality 51% 68%

10 Summary of Landmark Trials HACA (European) Bernard (Australian) Initial rhythm VF or VT VF Pre ED Cooling No Yes Target Temp 32 to 33 C 33 C Hypothermia patients Standard Rx Patients Hypothermia duration 24 hours 12 hours Morbidity Reduction ARR 16%, NNT 6 ARR 16%, NNT 4 Mortality Reduction ARR 14%, NNT 6 ARR 17%, NNT 6 Adverse events (sepsis, arrhythmias & Bleeding) NS NS HACA study group, NEJM, 2002 & Bernard SA, NEJM 2002

11 THERAPEUTIC HYPOTHERMIA ARR equals the difference in risk of the outcome in question in both groups. NNT, is equal to 1/ARR. The NNT represents the number of people who would need to be treated with the intervention in order to prevent 1 adverse event. Acute myocardial infarction Angiotensin-converting enzyme (ACE) inhibitors vs. placebo 30 Days Mortality NNT: 210

13 HACA Recommendations

14 POST CARDIAC ARREST SYNDROME The complex pathophysiological processes that occur following whole body ischaemia during cardiac arrest and the subsequent reperfusion response following successful resuscitation.

15 Pathogenesis of hypoxic ischaemic injury

16 Life cycle of cardiac arrest ATP breakdown/anaerobic glycolysis Failure of energy dependent pumps and acidosis Excess calcium in cell-ffa and oxygen free radical production and lipolysis Excess K and Na in cells Cerebral hypoperfusion even with a good systemic blood pressure (for 24 hours or longer)

17 Complications of return of spontaneous circulation Reperfusion injury (increased oxygen free radical production leads to apoptosis) Initiates a cascade of events (increased intracellular calcium-glutamate calcium) Inflammatory response (causes high levels of cytokines) Activation of coagulation cascade Ischemia/reperfusion injury leads to cerebral edema (increased permeability of blood brain barrier, vasculature and cell membranes) Hypoxia and reperfusion start all of these biochemical events but they can persist or hours or days.

18 HOW DO YOU PREVENT IT? COOL THEM DOWN!!! INDUCE HYPOTHERMIA

19 BENEFITS OF THERAPEUTIC INDUCED HYPOTHERMIA Decreases cerebral metabolism therefore decreases the need for oxygen(6-8% per 1 0 C) Reduces the cellular levels of glutamate Reduces intracellular acidosis Decreases the inflammatory response and cytokine release Protects the blood brain lipomembranes Hypothermia suppresses apoptosis Attenuation of oxygen free radical production and lipid peroxidation. In the heart, hypothermia may decrease the area of injury, promote epicardial reflow, decrease myocardial metabolic demand, and preserve intracellular highenergy phosphate stores.

20 FROM THEORY TO EXECUTION

21 HYPOTHERMIA PROTOCOL Identification of eligible patients Identification of ineligible patients Cooling induction Maintenance Rewarming Disposition

22 HYPOTHERMIA PROTOCOL Identification of eligible patients Comatose survivors after out-of-hospital cardiac arrest with a primary rhythm of VT/VF regardless of presence of shock. Hypothermia should be considered for non- VF rhythms and in-hospital cardiac arrest 60 min CPR prior to ROSC Time of initiation of hypothermia less than 6 hours post cardiac arrest Pre-arrest GCS = 15

23 Does Rhythm Matter? Data from RCTs Suggest VF and VT Combination of rhythms during a cardiac arrest event Underlying mechanisms of brain injury are same Multiple observational trials on asystolic rhythm have shown benefit TH induction applies on the discretion of the treating practitioners

24 Do Circumstances of Arrest Adequately Predict Outcome? Practice Parameters: Prediction of outcome in comatose survivors after cardiopulmonary resuscitation, NEUROLOGY 2006;67:

25 HYPOTHERMIA PROTOCOL Identification of ineligible patients Written DNR/DNI Cognitive status severely impaired before arrest Underlying coagulopathy or bleeding disorder Other known reason for coma/arrest (e.g. septic shock, severe acidosis, trauma, etc.) Questionable head injury or head CT with mass or hemorrhage Unstable cardiac rhythms not terminated during initial management Pregnancy Recent major surgery within the last 14 days

27 ΤΕΧΝΙΚΗ ΠΡΟΚΛΗΣΗΣ ΥΠΟΘΕΡΜΙΑΣ Βάση 4 μηχανισμών απώλειας θερμότητας Ακτινοβολία Μεταφορά Μεταγωγή Εξάτμιση ΜΕΘΟΔΟΙ ΥΠΟΘΕΡΜΙΑΣ ΚΕΝΤΡΙΚΗ ΨΥΞΗ ΠΕΡΙΦΕΡΙΚΗ ΨΥΞΗ

28 Methods and devices for TH Surface cooling: Air Exposure Exposure plus water or alcohol sprays Fans Air circulating cooling blankets Surface cooling: Fluids Ice packs Complete immersion in cold water Circulating cold water directly against skin Prerefrigereted cooling pads Water-circulating cooling blankets Core cooling Infusion of ice-cold (4oC) fluids Peritoneal lavage device Extracorporeal circulation Intravascular catheters

29 ΤΕΧΝΙΚΗ ΠΡΟΚΛΗΣΗΣ ΥΠΟΘΕΡΜΙΑΣ ΠΕΡΙΦΕΡΙΚΗ ΨΥΞΗ

30 Επιφανειακά μέσα παγοκυψέλες

31 Επιφανειακά μέσα σκούφος Διάλυμα γλυκερόλης

32 Επιφανειακά μέσα κουβέρτα αέρα

33 GAYMAR III Κουβέρτα νερού η γέλης

34 A COLD NOSE AND A COLD BRAIN Brain T 2,4 0 /h Body T 1 0 /h The RhinoChill

35 ΤΕΧΝΙΚΗ ΠΡΟΚΛΗΣΗΣ ΥΠΟΘΕΡΜΙΑΣ ΚΕΝΤΡΙΚΗ ΨΥΞΗ Ενδοφλέβιοι καθετήρες Εξωσωματική κυκλοφορία Χορήγηση παγωμένων υγρών (4 ο C)

36 Ενδαγγειακός καθετήρας

37 Ενδαγγειακός καθετήρας

38 Cool Line Catheter The Icy Catheter υποκλείδιος μηριαίος

39 Cool Line Catheter -8.5 or 9.3 Fr guidewire (Seldinger technique) -22 cm long -Duraflo (Heparin) coated -Radiopaque -Insertion Kit 4 mm 5 mm Heat exchange balloons

40 Αρχή Λειτουργίας του Καθετήρα Το αίμα αποκτά την επιθυμητή Θερμοκρασία κατά την επαφή του με τα μπαλόνια

41 ΣΥΝΔΥΑΣΜΟΣ ΜΕΘΟΔΩΝ Coolgard NaCl 0.9% θερμοκρασία 4 C Bruel C, Crit Care, 2008, 12:R31

42 COMPARISON OF METHODS ICE BAGS FANS INTRAVENOUS FLUIDS MECHANICAL ENDOVASCULAR INEXPENSIVE,WIDELY AVAILABLE INEXPENSIVE,WIDELY AVAILABLE INEXPENSIVE,WIDELY AVAILABLE FAIR CONTROL OF PATIENTS TEMPERATURE BUT EASY TO USE RELIABLE CONTROL OF PATIENTS TEMPERATURE,FAST,NO RISK OF SKIN LESION MESSY,DIFFICULT TO CONTROL TEMPERATURE DIFFICULT TO CONTROL T, LIMITED ABILITY TO DECREASE T QUICKLY NEED TO DETERMINE WAYS TO KEEP FLUIDS COLD VARIETY OF SYSTEMS,COSTS,NOT EASILY TRANSPORTABLE EXPENSIVE,LARGE INVASIVE LINE,INCREASED RISK OF SEPSIS

43 HYPOTHERMIA PROTOCOL Cooling induction If eligible, activate CHILL team Similar to STEMI team Prior to cooling Intubate patient Insert arterial pressure monitoring line Insert CVC (preferably Edwards SVO2) catheter Insert temperature sensing Foley catheter (oliguria) Sedate with IV Midazolam and Fentanyl Paralyze with Vecuronium to prevent shivering

44 HYPOTHERMIA PROTOCOL Cooling induction ASAP Target temperature and duration? 32 C-34 C for 24 h after initiation of induction. Goal maximum 6 hrs to target temperature. Methods of induction? Ice-cold LR or NS 30 ml/kg with pressure bags via large bore cannulas in 30 minutes time Avoid in patients with pulmonary edema or severely reduced LV systolic function. Combine with cooling device. Our institution has Coolgard 3000 readily available.

45 HYPOTHERMIA PROTOCOL Cooling induction Hypothermia and STEMI? Proceed to Cath lab for PCI with continuation/induction of cooling and continuous temperature measurement must be provided. Follow ERC Guidelines

46 HYPOTHERMIA PROTOCOL Maintenance Maintain temperature 32 C-34 C for 24 h after initiation of cooling Nursing to monitor Temp, MAP, CVP, SVO2, hourly & record on specific TH flowsheet If Swan-Gantz Catheter in place also monitor SVR, CI Labs q6h Lactate, BMP, CBC, Trop/CK/CK-MB, ABG (corrected for temperature) Maintain tight glycaemic control Do not provide nutrition at any stage of TH

47 HYPOTHERMIA PROTOCOL Maintenance Side Effect Monitoring Bradycardia higher risk if Temp < 30 C. Lidocaine if recurrent VT/VF Closely monitor for infection, no evidence for prophylactic antibiotics despite higher rates of sepsis & pneumonia Closely monitor for electrolyte imbalance. Potentially higher bleeding complications after PCI. Platelet function unaltered by hypothermia. Altered drug action and metabolism. Reduces systemic clearance of cytochrome P450 metabolized drugs between 7%-22% per C. Paralyze to prevent shivering

48 Therapeutic hypothermia: Side effects Effect Frequency Treatment Comment Hypovolemia Frequent Yes In TBI Cadiovascular changes Frequent No ECG changes Frequent Usually no Electrolyte disorders (loss K, Mg, P, Ca) Frequent Yes In TBI, rewarming phase Coagulopathy/bleeding Shivering Increased infection risk (respiratory, wound) Insulin resistance, hyperglycemia Bedsores Lab changes: Amylase, liver enzymes, lactates Frequent/rare Frequent Intermediate Frequent Intermediate Frequent Frequent Usually no Yes Yes Yes Yes Yes Yes Mg, analgesia, sedation Antibiotic prophylaxis? Changes in drug clearance (usually decrease) Adjust infusion rate

49 HYPOTHERMIA PROTOCOL Rewarming Goal is to rewarm over 6-8 hours Using Coolgard 3000 increase equipment setting by 0.5 C every 1-2 hours Discontinue paralytics when patient reaches 36 C. Discontinue K infusions and monitor for hypotension Maintain normothermia (36.5 C-37.5 C) up to 72 hrs after cardiac arrest. Do not rewarm too quickly

50 HYPOTHERMIA PROTOCOL Disposition Neurology Although decisions to proceed with care or withdraw care may take place at later times for a variety of reasons, the most useful signs occur at least 24 hours and in the case of motor response at 72 hours post cardiac arrest. Booth, JAMA 2004

51 HYPOTHERMIA PROTOCOL Disposition Home Rehab Long-Term Facility Long-Term Facility

52 ΔΥΝΗΤΙΚΕΣ ΕΦΑΡΜΟΓΕΣ

53 Συστάσεις 2010 γιατηχρήσητηςυποθερμίας Classes of Recommendations CPR Class I TBI Class I for ICP lowering Class IIA for fever Neonatal Asphyxia Class I Fever Class II B Stroke Class III Intra operative Class III

54 ΕΥΧΑΡΙΣΤΩ ΠΟΛΥ

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