slides rosc lecture 3 part 3
TRANSCRIPT
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Arrest ROSC
2. When to s tart
coo l ing?
3. How deep
to cool?
1. How to cool?
4. How long to
keep cool?
temperatu
re
time
Practical issues of coolingPractical issues in therapeutic hypothermia
Time
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University of ChicagoHospitals (UCH)initial experience (2003-4):
cooling blanketand/or ice packing
Advantages: cheap, non-invasive, off the shelf
Disadvantages: slow cooling, can be messy,lack of thermostatic control
How to cool?Our initial experiences with hypothermia
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Merchant RM et al, 2006
Retrospective chart review of cooling cases
From three hospitals (2 in U.S., 1 in U.K.)
Found 20/32 cases (63%) were overcooled
Trends towards better outcome in non-overcooled pts
Suggests need for thermostatic feedback control
Difficulties with ice bag coolingOvercooling using ice for hypothermia
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0 4 8 12 16 20 24 28 32
Time (hours)
Temperature(Ce
lsius)
Example A
Merchant RM et al, 2006
Surface cooling in the real worldAn example of a patient cooled with ice
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Cooling was fast
65% cooled to target
within 60 minutes
77% failed to stay
cool during course
But maintenance was hard
Is cold saline enough?What about cold intravenous fluids?
Cold infusions alone are effective for induction of therapeuticHypothermia but do not keep patients cool after cardiac arrest
Kliegel et al, 2007
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Study at one hospital in Switzerland
Survivors of out-of-hospital arrest
Cooling initially via ice bags, then cooling mattress
Target temperature 33oC, maintained for 24 hrs
Oddo M et al, 2006
Real world usage: SwitzerlandAn example from the real world of cooling patients
From evidence to clinical practice: Effective implementation of
therapeutic hypothermia to improve patient outcome aftercardiac arrest
Oddo et al, Critical Care Medicine 2006
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CPC5 CPC3 CPC2 CPC156% 19% 12% 14%
CPC 5 .CPC3 CPC2 CPC140% 5% 14% 42%
Outcome at discharge for out-of-hospital VF arrest
baseline
cooling
Real world usage: SwitzerlandA real world example: cerebral performance category (CPC) outcomes
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Real world usage: Switzerland
CPC5 CPC389% 11%
CPC5 CPC183% 17%
baseline
cooling
Outcome at discharge for out-of-hospital asystole arrest
A real world example: cerebral performance category (CPC) outcomes
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Post-arrest care is a critical care bundle:
Therapeutic hypothermia
Careful blood pressure management
Treatment for coronary blockages
Brain and outcomes assessment
Post-arrest care is more than just cooling
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Hypothermia resource websiteA public resource for more hypothermia information
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Hypothermia Training Institute at Penn
Phi ladelphia next cou rse March , 2013
Intensive two day CME course in hypothermiamethods, protocols, and applications
Designed for critical care, cardiology or emergency medicine
physicians and nurse managersi.e., local champions
Offers hypothermia certification
Workshop designsmall course sizeheld quarterly
Training program for health care providers
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Upcoming Coursera lectures in this program
Lecture 2: Rethinking CPR: quality of care andnew ideas about training
Lecture 3: Therapeutic hypothermia and post-resuscitation care
Lecture 4: Frontiers in resuscitation: reperfusionmedicine and cardiac bypass
Lecture 5: Survivorship and end-of-life issuesafter cardiac arrest