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
Present Prehospital Cardiac Arrest Outcomes 50% No ROSC 25% Die in Hospital 10% Brain Damage 25% Leave the Hospital 15% Good Outcome
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.
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 82.4-90ºF ) Severe (20-28ºC or 68-82.4ºF) Profound ( < 20ºC or < 68ºF)
THERAPEUTIC HYPOTHERMIA Therapeutic hypothermia: Controlled induced hypothermia (potentially deleterious effects being controlled or suppressed) 32-34 0 C Ισορροπία μεταξύ κλινικού αποτελέσματος και καρδιαγγειακής τοξικότητας θ<31 0 C -Slow AF θ<28 0 C- VF
Ιστορική αναδρομή της Θεραπευτικής υποθερμίας Ιπποκράτης 450 πχ Baron Larrey, 1814 χειρουργός του Ναπολέοντα
Ιστορική αναδρομή της Θεραπευτικής υποθερμίας Πρώτες μελέτες πριν 50 χρόνια Κύριοι λόγοι εγκατάλειψης: ανεπιθύμητες ενέργειες & αβέβαια αποτελέσματα Anesth.Analg.1959 1990 Πειραματικές μελέτες 3 Κλινικές μελέτες το 2001 2002 (ΝΕJM ) Συστάσεις από 2003
ΜΕΤΑ ΚΑΡΔΙΟΑΝΑΠΝΕΥΣΤΙΚΗ ΑΝΑΚΟΠΗ
ΜΕΤΑ ΚΑΡΔΙΟΑΝΑΠΝΕΥΣΤΙΚΗ ΑΝΑΚΟΠΗ European Study: HACA - 275 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%
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 136 43 Standard Rx Patients 137 34 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
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
HACA Recommendations
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.
Pathogenesis of hypoxic ischaemic injury
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)
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.
HOW DO YOU PREVENT IT? COOL THEM DOWN!!! INDUCE HYPOTHERMIA
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.
FROM THEORY TO EXECUTION
HYPOTHERMIA PROTOCOL Identification of eligible patients Identification of ineligible patients Cooling induction Maintenance Rewarming Disposition
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
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
Do Circumstances of Arrest Adequately Predict Outcome? Practice Parameters: Prediction of outcome in comatose survivors after cardiopulmonary resuscitation, NEUROLOGY 2006;67:203 210
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
ΤΕΧΝΙΚΗ ΠΡΟΚΛΗΣΗΣ ΥΠΟΘΕΡΜΙΑΣ Βάση 4 μηχανισμών απώλειας θερμότητας Ακτινοβολία Μεταφορά Μεταγωγή Εξάτμιση ΜΕΘΟΔΟΙ ΥΠΟΘΕΡΜΙΑΣ ΚΕΝΤΡΙΚΗ ΨΥΞΗ ΠΕΡΙΦΕΡΙΚΗ ΨΥΞΗ
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
ΤΕΧΝΙΚΗ ΠΡΟΚΛΗΣΗΣ ΥΠΟΘΕΡΜΙΑΣ ΠΕΡΙΦΕΡΙΚΗ ΨΥΞΗ
Επιφανειακά μέσα παγοκυψέλες
Επιφανειακά μέσα σκούφος Διάλυμα γλυκερόλης
Επιφανειακά μέσα κουβέρτα αέρα
GAYMAR III Κουβέρτα νερού η γέλης
A COLD NOSE AND A COLD BRAIN Brain T 2,4 0 /h Body T 1 0 /h The RhinoChill
ΤΕΧΝΙΚΗ ΠΡΟΚΛΗΣΗΣ ΥΠΟΘΕΡΜΙΑΣ ΚΕΝΤΡΙΚΗ ΨΥΞΗ Ενδοφλέβιοι καθετήρες Εξωσωματική κυκλοφορία Χορήγηση παγωμένων υγρών (4 ο C)
Ενδαγγειακός καθετήρας
Ενδαγγειακός καθετήρας
Cool Line Catheter The Icy Catheter υποκλείδιος μηριαίος
Cool Line Catheter -8.5 or 9.3 Fr -.032 guidewire (Seldinger technique) -22 cm long -Duraflo (Heparin) coated -Radiopaque -Insertion Kit 4 mm 5 mm Heat exchange balloons
Αρχή Λειτουργίας του Καθετήρα Το αίμα αποκτά την επιθυμητή Θερμοκρασία κατά την επαφή του με τα μπαλόνια
ΣΥΝΔΥΑΣΜΟΣ ΜΕΘΟΔΩΝ Coolgard NaCl 0.9% θερμοκρασία 4 C Bruel C, Crit Care, 2008, 12:R31
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
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
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.
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
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
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
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
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
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
HYPOTHERMIA PROTOCOL Disposition Home Rehab Long-Term Facility Long-Term Facility
ΔΥΝΗΤΙΚΕΣ ΕΦΑΡΜΟΓΕΣ
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
ΕΥΧΑΡΙΣΤΩ ΠΟΛΥ