Shyama Marshall RN, BSN Clinical Nurse II, Neuroscience ICU UCI

NK8s, Thermogard.pdf
Shyama Marshall RN, BSN
Clinical Nurse II, Neuroscience ICU
UCI Medical Center
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NK8s, Thermogard.pdf
Introduction/Background
 One of the challenges to registered nurses is hypothermia
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in burn ICU patients and uncontrollable fever in neuropatients and post-cardiac arrest patients.
Maintaining temperature in these patients to a therapeutic
level with conventional methods is very challenging.
Uncontrolled temperature has a direct/indirect effect on
the patient outcome
Shivering and abnormal temperature, uncontrolled by
conventional methods, have unknown effects on the
patient’s recovery.
Thermogard will aid patient’s recovery through the neuroprotective effects of induced hypothermia/normothermia
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NK8s, Thermogard.pdf
Thermogard-induced hypo or normothermia:
Introduction
 Improves neurological outcome in neuro and postcardiac arrest patients
 By regulating pt’s temp. Thermogard lessens pt’s
length of hospital stay, requires less nursing
interventions and is therefore cost-effective.
 Thermogard is a machine from which cooled sterile
saline flows through the central line catheter
thereby regulating pt body temp. without direct
contact of saline with the pt’s blood.
NK8s, Thermogard.pdf
Goals of Project:
 Familiarize nursing staff with the current research on
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the use of normothermia and induced hypothermia.
Help patients to recover with less neurological damage
by controlling or maintaining target temperature.
Reduce patient’s temperature-related complications.
Reduce skin-related issues, common in conventional
fever-reducing methods
Familiarize nursing staff with the use of Thermogard.
Increase and improve staff knowledge, competency
and confidence in using the Thermogard for induced
hypothermia and normothermia.
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NK8s, Thermogard.pdf
Methodology
 Educational in-service /Class for nurses
 Train super-users – “Train the trainer” for
inpatient nurses on the use of Thermogard
 Develop a competency checklist
 Develop a pre and post-inservice/class test
 Develop guidelines and order sets on the use of
Thermogard -therapeutic hypothermia and
normothermia.
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NK8s, Thermogard.pdf
What are the current guidelines?
Cardiac Arrest- out of hospital
• Adult patients who are comatose with spontaneous
circulation after out-of-hospital VF cardiac arrest
should be cooled to 32°C to 34°C for 12 to 24 hours.
• Executive Summary
2010 International Consensus on Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care Science With Treatment
Recommendations
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Current Stroke Guidelines
• The 2007 AHA guidelines
• recommend keeping the patient normothermic
(Level 2; Adams et al., 2007).
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NK8s, Thermogard.pdf
Current Stroke guidelines
• Temperature should be monitored.
• Temperature elevation has been associated with
increased mortality and morbidity in an acute stroke.
• The fever increases metabolic demands
of the brain, which can worsen the ischemia
and lead to further tissue damage.
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NK8s, Thermogard.pdf
 In the stroke population, hyperthermia
within the first 24 hours correlates with
a mortality rate of 78%, compared with 2% in
normothermic patients (Castillo et al., 1994).
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NK8s, Thermogard.pdf
Stroke Guidelines
 Research is studying the use of hypothermia for acute
stroke and head injury, but data supporting its use are
insufficient
 Guide to the Care of the
Hospitalized Patient with Ischemic Stroke
 2nd Edition, Revised
 AANN Clinical Practice Guideline Series
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Brain Trauma Foundation issued
Level 3 recommendation in 2008
 Cautious use of induced hypothermia
 The analysis suggests that hypothermia maintained for
more than 48 hours reduces mortality and results in
favorable neurological outcomes when they are
measured 1–2 years post injury
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 Maintaining Normothermia May Prevent ICP
Increases (Level 2)
 There have been no long-term outcome studies
on the effects of normothermia in a TBI population.
 One descriptive study of 20 patients, 10
of whom sustained acute TBI, found an increase
in brain temperature was associated with a significant rise in
ICP;
(Rossi, Zanier, Mauri,
Columbo, & Stocchetti, 2001).
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NK8s, Thermogard.pdf
Burn Research:
Improves comfort level, allows for longer surgical
procedures. Facilitates wound debridement, excision and
grafting in burn patients and also minimizes complications
NK8s, Thermogard.pdf
Conventional Cooling Methods
• Conventional cooling methods and therapies in use
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have led to inconsistency in controlling/maintaining
patient’s temperature in a desired range:
External warming methods
External cooling methods
A) tepid sponge
B) ice packs to axillae, groins, cranio-cervical areas
C) cold saline or ice water lavage through NG tube.
D) cooling blanket -anterior and posterior
E) anti-pyretic drugs
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Use of the Thermogard
NK8s, Thermogard.pdf
Research Questions
• Intravascular temperatrure regulation (induced hypothermia) is
it the right way to minimize the neurological or cardiac
complications? Does it increase the survival rate?
• Mild or moderate hypothermia. Which is the option for
achieving the right temperature to minimize or improve
neurological and cardiac outcomes?
• Does therapeutic hypothermia or normo thermia prevent
secondary brain injury and provide neuro protection?
• Mild or moderate or deep hypothermia for whom? When do we
start? (timing) What is the duration? Does it improve survival
rate by preventing secondary complications in stroke and
cardiac arrest patients?
NK8s, Thermogard.pdf
Hypothesis
 We should be cooling in-hospital cardiac arrest
patients as well as out of hospital cardiac arrest
patients
 Induced hypothermia in the TBI and Stroke patient
will improve neurological outcomes and decrease
mortality-
 need further research to support these statements
NK8s, Thermogard.pdf
Conclusion
•Studies have shown that there is a correlation between body temperature and initial
stroke severity ,infarct size, outcome and mortality.
•In cerebral ischemic patients, small changes in the temperature of the ischemic brain
tissue may alter survival of neurons.
•Excitatory amino acids, oxygen free radicals and inflammatory cytokines appear within
minutes of brain injury/ischemia and lead to secondary brain injury.
•If Therapeutic Hypothermia is induced in such patients without any delay, its
mechanism of action reduces the levels of these mediators of secondary brain injury.
But requires more research .
•Should we use Therapeutic temperature regulation with Thermogard to manage our
pts temperature and prevent secondary complications in Post Cardiac Arrest pts,
Neuro pts and Burn pts ?
NK8s, Thermogard.pdf
Literature Reviewed
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Critical Care Nurse, Induced hypothermia for Patients with cardiac arrest: Role of Clinical Nurse Specialist. (2007). 27,5, 36-42
http://cln.aacnjournals.org
King B, Corallo J.P. & Luo, X. (YEAR) Using an intravascular warming catheter to maintain normothermia during burn excision.
UNMSM, University of Miami, J.M. Hospital
Nolan, J.P., Morley,P.J. et al. Therapeutic Hypothermia after cardiac arrest: an advisory statement by the Advanced Life Support
Task Force of the International Liason Committee on Resuscitation – Circulatory Journal of the American Heart Association.(
2003) 108, 118-121 American Heart Association. Granville Avenue, Dallas TX
(2010, April 1) LA marathon cardiac arrest victim doing well after induced hypthermia treatment at UCLA
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pp. 79-82. Retrieved in 30 April 2010 from http://journals.Iwco.com/co-criticalcare/fulltext/2009
Paccio, M.A., Fischer, R.M. et al. Induced normathermia attenuates intracranial hypertension and reduces fever burden after
severe traumatic brain injury. Journal of Neuro-critical Care Vol. 11, No. 1, August 2009 PAGE NUMBERS
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unit patients: a prospective intervention study. Aug 24, 2007. Critical Care 2007, Vol 11:R91. Retrieved from
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Romes, G.E., Rester, M et al. (2002)Periopatric Hypothermia in Burn Patients subjected to non-extensive surgical procedures.
Annals of Burns and Fire Disasters. Vol. XV. No. 3 September 2002
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Nettina, M.S. (2001) Manual of Nursing Practice (7th Ed) Lipincott Philadelphia
Bader, M.K., & Littlejohns, L.R. (2004) AANN Core Curriculum for Neuroscience Nursing (4th Ed) Elsiever Inc St Louis
Missouri
Mayer, S.A., & Sessler, D.I. (2005) Therapeutic Hypothermia. Marcel Dekker, New York
NK8s, Thermogard.pdf
Literature Reviewed[contd.]
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Puccio & Fischer et al “Induced Normothermia Attenuates Intracrnial Hypertonin and Reduces fever burden after severe traumatic Brain Injury”
Neurocritical Care (2009) 11:82-87 Neurocritical Care Society published on 1 April 2009 dept of Neurological Surgery University of Pittsburg Medical Center
ALSIUS reference – www.alsius.com. Tel 1-877-2ALSIUS Alsius Operating Manual
Lasater, M. “Treatment of Severe Hypothermia with Intravascular Temperature Modulation” Critical Care Nurse Vol 28, No 6 Dec 2008
http://ccn.aacnjournals.org
Center for Disease Control and Prevention. Hypothermia - related monthly – Montana 1999-2004 MMWR Mob Mental Wkly Rep 2007; 56(15): 367-368
O’Grady, P.N. & Barrie, S.P. et al (2008) “Guidelines for Evaluation of new fever in critically ill adult patients: 2008 update from the American College of
Critical Care Medicine and the Infectious Diseases Society of America. Critical Care Med 2008 Vol.36 No 4 Lippincott Williams & Wilkines
Leaper, D. & Kumar,S. et al. Maintaining Normothermia During Surgery. Retrieved on 8/26/10 at http://www.hosintint.net/categories/hypothermia/maintaining_normothermia_during_surgery
Glance@Vancouver hospital themes and protocols for hypothermia/N
Muchelberger,T. & Ottoman, C. et al. Emergency Pre-hospital care of burn patients. The Surgeon 8 (2010) 101-104 Elsevier. Retrieved at www.thesurgeon.net
Corallo, J.P. Core Warming of a burn patient during excision to prevent hypothermia. Burns (2007) doi 10.1016/J.Burns.2007.08.012
Brunas, B.E. et al. Hypothermia and Bruns: A meta-analysis. Annals of Burns and Fire Disasters. Vol. XVI-n.2 June 2003. Retrieved on 8/26/10
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