Eligibility Criteria

Hospital of the University of Pennsylvania BCC-04-05 HUP Nursing Practice NURSING Manual

Clinical Practice Post Cardiac Arrest Targeted Temperature Page 1 of 9 Policy/Procedure Management Nursing Care

INTRODUCTION KEYWORDS: Patients undergoing post-cardiac arrest resuscitation (PCAR) and Cooling targeted temperature management (TTM) will have nursing care provided according to the following policy. REFER TO: SCOPE HUP Policy 1-12-22 Pain Assessment Registered Nurses (RNs) working in the Emergency Department (ED) and adult Critical Care Units in which use of the PCAR and TTM are CCC-05-05 Use of Bispectral approved by the Medical Director. Index (BIS) Monitoring ELIGIBILITY CRITERIA 4A-03-22 Eye Care A. Patient post-cardiac arrest: defined as absence of pulses HUP Formulary requiring chest compressions, regardless of location or presenting rhythm with subsequent return of spontaneous 4A-02-05a Electronic circulation (ROSC). Documentation of Medication Administration B. Less than 12 hours have elapsed since ROSC (Return of Spontaneous Circulation). BCC-03-26 Neuromuscular Blocking Agent C. Patient does not have an order for Do Not Attempt Resuscitation (DNR) B or C; or a Do Not Intubate (DNI).

D. Patient’s pre-arrest cognitive status is not severely impaired (Glasgow Coma Score [GCS] =15 or performed ADL independently).

E. Patient is comatose at enrollment with a Glasgow Motor Score <6 (doesn’t follow commands) pre-sedation.

F. No other obvious reasons for coma.

G. No uncontrolled bleeding.

H. No evidence of uncontrollable dysrhythmias.

I. No pre-existing multi-organ dysfunction syndrome, severe sepsis, or metabolic acidosis as a cause of arrest.

J. No comorbidities with minimal chance of meaningful survival independent of neurological status.

BACKGROUND

Brain temperature during the first 24 hours after resuscitation from cardiac arrest may have a significant effect on survival and neurological recovery. Cooling to 32-34°C for 24 hours decreases the chance of death and increases the chance of neurological recovery. Hospital of the University of Pennsylvania BCC-04-05 HUP Nursing Practice NURSING Manual

EFFECTS OF TARGETED TEMPERATURE MANAGEMENT

A. Hypothermia activates the sympathetic nervous system causing vasoconstriction and shivering. Shivering increases O2 consumption by 40-100%. Thus, shivering must be prevented during hypothermia and is best accomplished by initiating neuromuscular paralysis prior to induction of hypothermia. Note: If paralysis is begun well after TTM has been initiated it can result in a precipitous drop in core body temperature. Elderly patients will cool more quickly than younger or obese patients.

B. Hypothermia shifts the oxyhemoglobin curve to the left and may result in decreased O2 delivery. However, the metabolic rate is also lowered, decreasing O2 consumption and carbon dioxide (CO2) production. Ventilator settings may need to be adjusted due to decreased CO2 production, using blood gases.

C. Hypothermia initially causes sinus tachycardia, then bradycardia.

1. Extremely important to keep temperature >30ºC. 2. Temperatures:

a. <30º C, increased risk for arrhythmias. b. <28º C, increased risk for ventricular fibrillation.

3. Severely hypothermic myocardium (<30°C) is less responsive to defibrillation and medications.

D. Hypothermia decreases cardiac output and increases systemic vascular resistance (SVR).

E. Hypothermia can induce an in vivo coagulopathy which is not detectable by laboratory testing (as blood is warmed during testing).

F. Hypothermia-induced diuresis is to be expected and should be treated aggressively with fluid and electrolyte repletion. Magnesium, phosphorus and potassium should be monitored closely and maintained in the normal range (because it will rebound to a higher value during rewarming).

G. Decreased insulin secretion and sensitivity leads to hyperglycemia, which should be treated aggressively.

H. Re-warming too rapidly can cause vasodilation, hypotension, and rapid electrolyte shifts.

I. Re-warming is begun 24 hours from the time target temperature is reached.

PROCEDURE

A. Provide Patient and Family Education Support.

1. Explain the purpose of TTM and the need for pharmacologic paralysis. 2. Encourage the family to continue to talk to the patient. 3. Provide emotional support and answer any questions. Hospital of the University of Pennsylvania BCC-04-05 HUP Nursing Practice NURSING Manual

4. Offer pastoral care support to the family. Facilitate communication between the family and the physicians, nurse practitioners (NP), and physician’s assistants (PA). 5. Neuroprognostication should not occur until 72 hours after rewarming.

B. Gather Equipment for Cooling.

1. Two one liter bags of cold (4ºC) 0.9% saline (stored in participating units’ medication refrigerators). 2. PreSep catheter and tubing set up. 3. Arterial catheter and tubing set up. 4. Gaymar III 7900 (Blue-faced) external cooling system (available on participating units) with two complete sets of hoses.

a. One Gaymar torso wrap. b. Two thigh cooling leg wraps (available through Gaymar company). c. Choose small-medium or large wraps depending on patient size for the most effective cooling. d. Weight of Gaymar wraps when filled:

1.) Large Torso: 3.0 lbs 2.) Medium/Small Torso: 2.5 lbs 3.) Each Leg: 2.0 lbs

5. Temperature probe indwelling bladder catheter. (Bard Temperature Sensing Foley 400 Series - product #90911616– no minimum urine output required for use) 6. 1/4-1/8” adapter for cooling device (stored with the Gaymar III). 7. Neuromuscular blockade equipment (not required for ED).

a. Peripheral nerve stimulator. (Refer to BCC-03-26 Neuromuscular Blocking Agent) b. Consider BIS monitor and sensor for monitoring sedation depth. (Refer to CCC- 05-05 Use of Bispectral Index (BIS) Monitoring)

8. Ensure fluid warmer is available for IVF in case need arises after cooling.

C. Preparation for Cooling:

1. Verify prescriber’s orders (SCM Post-Cardiac Arrest/Targeted Temperature Management Order set) 2. Notify Resuscitation Consult Team: 267-253-9035 3. Ensure arterial catheter is inserted BEFORE or SIMULTANEOUS with initiation of cooling, as it is difficult to place once the patient is cooled. Central venous access (CVC) is not required immediately, providing the patient is hemodynamically stable and has good peripheral access; however, it should be placed expeditiously to guide post-arrest resuscitation. Although any CVC is acceptable, use of the PreSEP triple lumen catheter is ideal for continuous venous oximetry monitoring. 4. Obtain baseline labs per prescriber’s order:  ABG with Ionized Ca+ and Magnesium Hospital of the University of Pennsylvania BCC-04-05 HUP Nursing Practice NURSING Manual

 CBC, Platelets, PT/PTT/INR, Fibrinogen  Electrolyte “panel 7”, phosphate, chloride, glucose  Amylase, lipase  Liver function panel  Lactate, CPK-MB, CK, Troponin  Cortisol level (if indicated)  Pan-culture: Blood Culture, Urine culture, Urinalysis, Sputum culture (if appropriate)  Toxicology screen (if appropriate)  Co-oximetry on a Central Venous blood sample  Beta HCG on all women of childbearing age

5. Place temperature probe indwelling bladder catheter (Bard Temperature Sensing Foley 400 Series - product #90911616 – no minimum urine output required for use). If bladder monitoring is not an option or temperature reading inaccurate, consider an alternative site, i.e. esophageal probe (CDR # 100158). NOTE: If bladder pressure is being performed, it is recommended that an esophageal probe be used for temperature monitoring. 6. Thorough skin assessment before applying cooling system wraps. Check skin, especially under the wraps, q 4 hours.

D. Cooling

1. Infuse intravenous (IV) fluids as per hypothermia protocol as needed.

a. Cold saline (4ºC) (up to 2 liters) may be used to facilitate cooling.

2. Administer medications per prescriber’s orders. (Refer to 4A-02-05a Electronic Documentation of Medication Administration)

a. Ensure adequate sedation using RASS initially. Following paralysis, BIS monitoring (with goal of 40-60) may be used to titrate sedatives. b. Initiate neuromuscular blockade before cooling (pancuronium is recommended unless there is concomitant renal or hepatic insufficiency; in which case cisatracurium should be used; Cisatracurium can be used if patients have renal insufficiency defined as a creatinine clearance <10 ml/min and/or hepatic insufficiency defined as total bilirubin >3mg/dl associated with liver disease or dysfunction (Refer to HUP Formulary). *If patient temperature is ≤ 34ºC on presentation, maintain temperature at 32- 34ºC with cooling blanket. Maintain paralysis until after rewarming is complete (36⁰C). Ensure adequate paralysis by using peripheral nerve stimulator (Refer to BCC-03-26 Neuromuscular Blocking Agent).

3. Gaymar Cooling Device: If using BLUE-faced Gaymar III set to Automatic mode, set point 33º Rapid mode, for 24 hours from time target temperature reached. Hospital of the University of Pennsylvania BCC-04-05 HUP Nursing Practice NURSING Manual

If using GRAY-faced Gaymar III set to Automatic mode, Rapid cooling, set point 34ºC. Once the patient reaches 34ºC set to Gradual mode at 33ºC.  Keep device plugged in at all times during use.  Make sure leg and chest wraps are filled before applying to the patient.  Apply circumferential torso pad and connect to first cooling hose.  Apply circumferential thigh wrap to each leg, connect leg wraps together in series, and then connect free ends to second cooling hose.  Connect temperature probe indwelling bladder catheter to temperature monitoring port on cooling device. Bard Temperature Sensing Foley 400 Series - product #90911616– no minimum urine output required for use)  If bladder monitoring is not an option or temperature readings inaccurate, switch to an alternative site, i.e. esophageal probe (CDR #100158), placed by physician, nurse practitioner or physician’s assistant.  Protect indwelling bladder catheter and temperature probe from coming in contact with cooling blanket wraps.  Check skin, especially under the cooling wraps, q 4 hours.  Ensure cooling blanket in- and out-flow tracts are unobstructed and that fluid is filling wraps when machine is turned on. You may need to add more water to device until plunger in tank rises to point where green line is seen.  Assess and document cooling blanket settings and patient’s temperature in °C.  Document patient temperature and blanket temperature on flowsheet in °C.

4. Cooling is maintained for 24 hours from time target temperature is reached.

E. Monitoring

1. Goal is to maintain patient’s core temperature between 32° and 34°C for 24 hours from time target temperature is reached. 2. Maintain blanket temp at 33°C automatic mode, follow patient temperature hourly.

a. If temp < 31° C, consider infusing 250 ml boluses of warm 40°C IV NSS or LR until temperature > 32°C. b. Monitor closely for arrhythmias when temperature < 32°C.

3. Hemodynamic Assessment:

a. Continuous venous oxygen saturation (ScvO2) with PreSEP™ catheter. b. Central venous oxygen saturation (ScvO2) every 6 hours and PRN if PreSEP™ catheter is not used. c. Maintain MAP 80-100 mm Hg, per hemodynamic algorithm, unless there are contraindications, e.g., acute coronary syndrome, aortic aneurysm. d. EEG must be started within 6-12 hours of TTM initiation and continued until re- warming complete and paralytics discontinued. Call the EEG Fellow at 215-404- 6771. For issues or concerns, if you cannot get a hold of the EEG fellow, please page the Neurology on call resident. Hospital of the University of Pennsylvania BCC-04-05 HUP Nursing Practice NURSING Manual

e. Somatosensory Evoked Potentials (SSEP): Order day 3 (72 hours-post-ROSC). Place order for SSEP in Sunrise with a note that states “post-cardiac arrest”. For questions call the lab at 215-662-2661.

4. Obtain laboratory values per prescriber’s orders:

a. Arterial blood gas (ABG) every 6 hours and as needed. b. Glucose, potassium (K+) and lactate every 6 hours until re-warming process complete (may require intensive glucose control and more frequent monitoring while cooled). c. Repeat Creatine phosphokinase-MB (CPK-MB), CK, Troponin every 6 hours until re-warming process complete. d. Complete blood count (CBC)/platelets/prothrombin time (PT)/partial thromboplastin time (PTT), electrolytes/blood urea nitrogen (BUN)/Creatine, Calcium/Magnesium/Phosphate every 6 hours until re-warming process complete. e. If continuous SvO2 catheter is not used, perform co-oximetry on Central Venous blood samples every 1-2 hours for the first 6 hours then q 6 and/or PRN as clinically indicated.

5. Urine output every 2 hours and more frequently if needed.

a. Hypothermia-induced diuresis is common. b. Aggressive IV fluid repletion may be required. c. Confirm decreased urine output with bladder scanner if acute decrease in urine output noted.

F. Re-Warming

1. Begin re-warming 24 hours after target temperature reached. 2. Re-warming too rapidly can cause vasodilatation, hypotension and rapid electrolyte shifts. 3. Prior to rewarming:

a. Volume load aggressively with Normal Saline to compensate for reductions in BP, Scv02, and central venous pressure (CVP). b. K+ shifts to extracellular compartment during re-warming.  STOP all K+ containing fluids.  However, always correct hypokalemia, and other electrolytes, to the normal range.

4. Re-warm gradually:

a. Maintain paralysis until patient reaches 36°C. b. Rewarm patient to a temperature of 37°C. Hospital of the University of Pennsylvania BCC-04-05 HUP Nursing Practice NURSING Manual

If using BLUE-faced Gaymar III with automatic re-warming algorithm, set to automatic mode, set point 37º Moderate mode. The moderate mode will increase the set point automatically 0.33° every hour (~12 hours).

Note: During re-warming, do not change mode from Automatic mode to Manual. This will re-set the re-warming algorithm and affect the re-warming time.

The Blue-faced Gaymar Medi-Therm III will re-warm the patient at the set temperature and speed based on the mode selected and will not allow the patient to re-warm any faster.

If using GRAY-faced Gaymar III with manual re-warming, set to manual mode and manually increase the blanket temperature 0.33ºC every 1 hour until the patient temperature reaches 36ºC.

5. Assess vital signs with CVP every 1 hour until temperature reaches 37°C. 6. Monitor K+ every 6 hours and more frequently if needed. 7. Monitor serum glucose levels closely because as insulin resistance resolves there is increased risk of hypoglycemia. 8. Follow ABGs as needed. Adjust ventilator settings accordingly with Respiratory Therapy and physician/Nurse Practitioner (NP)/physician assistant (PA) collaboration. 9. Anticipate reduction in venous return (cardiac output) and BP (with ↓CVP) as cooler blood shifts from core to extremities. Follow CVP, ScVO2, UO and exam closely; aggressive IV fluids may be necessary to maintain adequate volume status and perfusion during re-warming. 10. Maintain paralysis until patient temperature > 36°C. Once temperature ≥36°C, paralysis can be stopped, BIS monitoring (if used) should be discontinued when train of four (TOF) is 4/4. Titrate sedation to comfort (RASS) and ventilator synchrony. (Refer to HUP Policy 1-12-22 Pain Assessment). 11. Obtain SSEP on day 3 (72 hours-post-ROSC) or later. Place order for SSEP in Sunrise with a note that states “post-cardiac arrest” or for questions call the lab at 215-662-2661. 12. Neuroprognostication should not take place until at least 72 hours after rewarming.

DOCUMENTATION

A. Nursing Flow sheet for Inpatient Units/Emtrac for ED patients:

1. Vital Signs. 2. Hemodynamics:

a. CVP b. ScvO2

3. Baseline and ongoing neurological exam, pain assessment and level of sedation/agitation. 4. Administration of analgesia, sedation and NMB agents. 5. Cooling blanket settings in °C with each change (use separate column). 6. Patient’s temperature in °C. Hospital of the University of Pennsylvania BCC-04-05 HUP Nursing Practice NURSING Manual

7. Eye care. 8. Skin care and repositioning.

B. Interdisciplinary Progress Notes:

1. Patient’s tolerance to the procedure. 2. Ongoing assessments. 3. Family updates.

C. Sunrise Clinical Manager (SCM): Medication Administration Record (MAR) (Refer to 4A-02-05a Electronic Documentation of Medication Administration)

1. Time infusion begun. 2. Dose administered. 3. Time infusion discontinued.

D. SCM Post-Cardiac Arrest/Targeted Temperature Management Order set. Hospital of the University of Pennsylvania BCC-04-05 HUP Nursing Practice NURSING Manual

REFERENCES

Arrich, J., Holzer, M., Herkner, H., Mullner, M. Cochrane corner: hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Anesth Analg. 2010: 110(4): 1239.

Rossetti, A.O., Oddo, M., Logroscino, G., Kaplan, P.W. Prognostication after cardiac arrest and hypothermia: a prospective study. Ann Neurol. 2010; 67(3): 30 107.

Hypothermia after Cardiac Arrest Study Group. Mild Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest. New England Journal of Medicine, 2002; 346(8):549-556.

Bernard, S.A., Gray, T.W., Buist, M.D., et al. Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest With Induced Hypothermia. New England Journal of Medicine, 2002; 346(8): 557-563.

Polderman, K.H. Application of Therapeutic Hypothermia in the Intensive Care Unit. Opportunities and Pitfalls of a Promising Treatment Modality--Part 2: Practical Aspects And Side Effects. Intensive Care Medicine, 2004; 30(5):757-69.

Zeiner, A., Holzer, M., Sterz, F., et al. Hyperthermia After Cardiac Arrest is Associated with an Unfavorable Neurologic Outcome. Arch Intern Med, 2001;161(16): 2007-2012.

REVIEWS/APPROVALS

Critical Care Practice Committee Emergency Department Leadership MICU Medical Director MICU Nurse Manager CCU Clinical Nurse Specialist Co-Directors, Clinical Center for Resuscitation Science

Supersedes: November 30, 2007; 5/29/09 Effective Date: May 19, 2010 Updated: May 1, 2012

Disclaimer

Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside the institution without administrative permission.