Neue Reanimationsforschung nach Herzstillstand

Neue Reanimationsforschung nach Herzstillstand

Cooling methods for
therapeutic hypothermia
after cardiac arrest
Wilhelm Behringer
Disclosure
Potential conflict of interest:
Co-founder, shareholder, and paid medical advisor for
EMCOOLS (Emergency Medical Cooling Systems AG),
Austrian start-up company, developing and producing
cooling devices for fast induction of hypothermia
How to cool?
US Army Research Institute of Environmental Medicine
Water
Immersion
Laboratory
Resuscitative hypothermia
Be Hot – Cool Down
Cooling faster = better?
Most probably!
cooling rate 0.3°C/h
Other cooling methods
Polderman KH
Keeping a cool head: How
to induce and maintain
hypothermia
Crit Care Med 2004 Vol.
32, No. 12
Pflügers Archiv, Bd. 263, S 145-165 (1956)
Resuscitative hypothermia – Cooling methods
• Clinical studies
– Invasive cooling
– Non-invasive cooling
– Out-of-hospital cooling
– Availability and costs
Resuscitative hypothermia – Cooling methods
• Clinical studies
– Invasive cooling
– Non-invasive cooling
– Out-of-hospital cooling
– Availability and costs
Clinical studies - Invasive cooling
30 ml/kg of
4°C RL i.v.
over 30 min
Clinical studies - Invasive cooling
2000 ml of 4°C RL
i.v. over 30 min
Clinical studies - Invasive cooling
2000 ml of 4°C RL
i.v. over 30 min
Clinical studies - Invasive cooling
Rapid Infusion of Ice-Cold Fluid to
Induce Therapeutic Hypothermia (RICH)
Kliegel et al. in press
2465 ±536 ml of 4°C
fluid i.v. over 30 min
• 20 patients
• temp on admission 35.2 (±1.1)°C
• Temp at start infusion 35.4 (±0.9)°C
• Temp after 30 min: 34.4 (±1.1)°C
• Temp after 60 min: 34.2 (±1.0)°C
• 13/20 patients reached target temperature
• 3/20 patients target temperature could be maintained
Clinical studies - Invasive cooling
Rapid Infusion of Ice-Cold Fluid to
Induce Therapeutic Hypothermia (RICH)
Kliegel et al. in press
2465 ±536 ml of 4°C
fluid i.v. over 30 min
36
35.5
35
34.5
34
33.5
33
0m
15 in (
m n=
2
30 in (n 0)
m =
2
i
45 n (n 0)
m =2
60 in (n 0)
m =
in 20
(n )
2h =2
(n 0)
=
3h 12
(n )
4h =9
(n )
5h =7
(n )
6h =5
(n )
7h =3
(n )
8h =3
(n )
9h =3
(n )
10 =3
h
)
(
n
11 =
h 3)
12 (n=
h 3)
(n
=3
)
Temperature (°C)
36.5
Time after start of infusion
Clinical studies - Invasive cooling
Endovascular cooling:
Clinical studies - Invasive cooling
Clinical studies - Invasive cooling
Clinical studies - Invasive cooling
Holzer et al. Stroke 2006
39
38
Temperature [°C]
Cooling rate of 1.2 (IQR 0.7-1.5) °C/h
37
36
35
75th Quartile
Median
34
25th Quartile
33
32
0
6
12
18
24
30
36
42
Time after restoration of spontaneous circulation [hours]
48
Intravasale Kühlung
Eine Methode zur Erzielung steuerbarer Hypothermie
Behmann F.W. und Bontke E.
Pflügers Archiv, Bd. 263, S 145-165 (1956)
Clinical studies - Invasive cooling
8 Patients
Extracorporeal temperature 28-30°C
Flow 200 ml/min
cooling rate of 3.5°C/h
Clinical studies - Invasive cooling
combination of cold fluid and endovascular cooling
Clinical studies - Invasive cooling
combination of cold fluid and endovascular cooling
Clinical studies - Invasive cooling
combination of cold fluid and endovascular cooling
Resuscitative hypothermia – Cooling methods
• Clinical studies
– Invasive cooling
– Non-invasive cooling
– Out-of-hospital cooling
– Availability and costs
Clinical studies – Non invasive cooling
ArcticSunTM - Medivance
Clinical studies – Non invasive cooling
ThermoWrap™ - Allon2001™
Clinical studies – Non invasive cooling
Blanketrol® III – CSZ
Clinical studies – Non invasive cooling
Deltatherm® - KCI
Clinical studies – Non invasive cooling
EMCOOLSpad
Clinical studies – Non invasive cooling
EMCOOLSpad
•
•
•
•
9/05 – 2/06: 12 patients
1 patient excluded due to sepsis
85 ± 22 kg
Baseline Tes: 35.9 (IQR 35.2-36.1)°C
– to Tes 34.0°C: 37 (IQR 29-45) min
– to target Tes 33°C: 54 (IQR 45-60) min
– cooling rate: 3.4 (IQR 2.5-3.9)°C/h
Clinical studies – Non invasive cooling
RapidCool™ - Medcool
NOTE: Neck collar not illustrated
MedCool, Inc.
Resuscitative hypothermia – Cooling methods
• Clinical studies
– Invasive cooling
– Non-invasive cooling
– Out-of-hospital cooling
– Availability and costs
Delay in cooling
Collaps -> CoolingStart (n=418)
ROSC -> CoolingStart (n=434)
131
159
0
20
40
60
80
100
120
140
min
Arrich J. HACA Registry.
160
Clinical studies – Out-of-hospital cooling
Clinical studies – Out-of-hospital cooling
30 ml/kg of 4°C RA
i.v. 100 ml/min
Clinical studies – Out-of-hospital cooling
EMCOOLSpad
Clinical studies – Out-of-hospital cooling
EMCOOLSpad
33.8°C on admission
MJ Foedisch, M Fischer - Bonn / FRG
Delay in cooling
Collaps -> CoolingStart (n=418)
ROSC -> CoolingStart (n=434)
131
159
0
20
40
60
80
100
120
140
min
Arrich J. HACA Registry.
160
Resuscitative hypothermia – Cooling methods
• Clinical studies
– Invasive cooling
– Non-invasive cooling
– Out-of-hospital cooling
– Availability and costs
Resuscitative hypothermia – Cooling methods
prices as quoted by Austrian distributors in the summer of 2006
Device
°C/h
Price
Cold i.v.
~3.0
cheap
Alsius
1.2
device: € 25.400
cath: € 615 + 275
Medivance
1.4
device: € 23.000
pad: € 710
Allon
0.5
device: € 9.400
pad: € 90
CZS
?
device: € 10.185
pad: € 331 -reuse
KCI
1.2
device: € 48.000
tent: € 250
Emcoools
3.4
not available yet
MedCool
0.9
not available yet
Induction
Invasive
Non-invasive
?
Maintenance
Rewarming
Conclusion
• Hypothermia after cardiac arrest: a must
• Invasive cooling
– with 4°C fluid
– endovascular cooling
• Non-invasive cooling
– some options available
– new options on the horizon
• Combination of cooling options
• Implementation of out-of-hospital cooling
Ötzi – the man from the ice. 4000 Years of no flow.
PRESERATIVE COOLING – A LONG TRADITION IN AUSTRIA
Be Hot – Cool Down