Protocol for Induced Therapeutic Hypothermia post cardiac arrest,For use in critical care by qualified health care practitioners BACCN Conference September 2010 Sarah Wallace, RGN, BSc (Hons) Gloucestershire Hospitals NHS Foundation Trust, Gloucester Royal Hospiatal,Protocol for Induced Therapeutic Hypothermia post cardiac arrest,Currently under journal publication submission process for Nursing in Critical Care - BACCN,Aim of teaching session,Discuss what is a protocol and why should clinicians follow one Pathophysiology of cardiac arrest What is and why induce hypothermia Awareness of physiologic consequences of hypothermia and associated treatment risks Management techniques for cooling and re-warming patients Introduction of Protocol for induced therapeutic hypothermia post cardiac arrest (including treatment guidelines and appropriate nursing interventions) Clinical goals of Neuromuscular Blockade (NMBA) Complications of hypothermia,What is a protocol,A protocol is a framework to support individuals or groups of staff to carry out interventions and is related to the specific skills and knowledge required. It describes specific intent, plans or processes, and specifies the criteria/boundaries which must be adhered to and is underpinned by evidence based information or practice (Glos Hospitals NHS Foundation Trust (2005) Trust Policies Framework),Why should we follow a protocol,To improve the quality of clinical care by using a standardised approach, ensuring uniformity and safety (Feldberg et al 2001) (Broccard, 2006) (Cushman et al, 2007) To provide a structure for clinicians when planning care for individual patients (Cushman et al, 2007) To follow a care plan based on the best possible research evidence (Topjian & Nadkarni, 2006) To assess the clinical effectiveness/safety of treatment/s and approaches (National Institute for Health and Clinical Excellence (NICE) Clinical Practice Guidelines)(Hoeksel, 2002) Research has suggested cooling post arrest from a cardiac aetiology may improve outcome and implementation of a protocol may decrease mortality rate (Arrich, 2007)(Zeitzer, 2005) To successfully apply induced hypothermia, the clinician should have experience in using and adherence to a strict protocol, vigilance and pay attention to the prevention of side effects to the patient (Polderman, 2004),Protocol use in post cardiac arrest patients,Using protocol in UK in 2006 28% (Lavar) Using protocol in USA in 2006 16% (Merchant) Using protocol in UK in 2008 83-85% (information taken from Society of Intensive Care of the West of England SICOWE Dec 2009 Junior Doctors Free Papers by Dr Andrea Binks Bristol Royal Infirmary Telephone research of 247 general ICUs in the UK with a 243 response - 98%) Anaesthesia, March 2010,Pathophysiology of cardiac arrest,Arrest due to cardiac dysfunction, drugs, drowning, hanging or severe asthma may lead to cerebral oedema/hypoxia Under normal circumstances the brain receives 15% of the cardiac output and consumes 20% of total body oxygen (Girolami et al, 1999) During cardiac arrest, the brain loses its oxygen stores within 20 seconds, leading to unconsciousness. Within 5 minutes of arrest, glucose and protein stores are depleted (Safar & Behringer, 2003), membranes depolarise and a neuroexitotoxic cascade occurs (Zanten, 2005), mitochondrial dysfunction is activated (Gunn & Thoresen, 2006), acidosis and electrolyte abnormalities are seen, the systemic inflammatory response is initiated and widespread necrosis/anoxic brain injury follows. Global hypoxic-ischemic injury is the result of this process. Reperfusion injury occurs with the return of blood circulation (Safar & Behringer, 2003) Mortality (death) ranges from 65-95% for out of hospital cardiac arrest and 40-50% for witnessed in hospital arrest (Birch, 2005),What is induced hypothermia,Induced hypothermia (IH) is defined as the controlled lowering of core temperature for therapeutic reasons (Bernard, 2003). 1.1C/hr median cooling rate (Arrich, 2007) Classification Mild: 35 32 C Moderate: 32 28 C Severe: 28 C (Polderman, 2004) Primarily for use in patients from pre-hospital cardiac arrest/ but may also be beneficial for other rhythms and/or in hospital arrest (Oddo et al, 2006)(Nolan et al, 2003)(Resuscitation Council, 2005)(Silvast, 2003)(Broccard, 2006) Mild hypothermic conditions of 32 - 34 C for 12-24 hours are ideal (Nolan et al, 2003/Resuscitation Council,2005/ILCOR, 2003/American Heart Association Guidelines, 2005/ Wright, 2005 & Bernard, 2004) The earlier the cooling initiated the better the outcome for the patient (Abella, 2004) Hypothermia can be achieved passively (no implemented treatment) or actively (invasively),Why induce hypothermia in post cardiac arrest,Resuscitation guidelines post cardiac arrest promote standardised care (Arrich, 2007) The European Resuscitation Council Hypothermia After Cardiac Arrest Register Mild therapeutic hypothermia may