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COLD HEARTED: Cool the Body, Save the Brain

Therapeutic Hypothermia offers new hope for patients after cardiac arrest

Published: Synapse 2011, Vol. 2

Most of us have witnessed this dramatic scene in a movie or on TV: A person collapses in cardiac arrest; bystanders administer CPR until EMTs arrive with a defibrillator, the heart starts beating again, and everyone breathes a collective sigh of relief. A heartbeat is a good sign, considering that only about 40,000 of the 300,000 Americans who go into cardiac arrest outside a hospital each year actually make it to the hospital.* But it's by no means an automatic happy ending: Fewer than 8-percent of these patients will survive.** Those who do are just beginning a long uphill climb to return to the lives they once knew. How far they make it often depends on how badly the brain was damaged.

Sue and Larry DavisSchool nurse, Sue Davis, credits the therapeutic hypothermia treatment she received at The Chester County Hospital as well as her husband Larry's quick thinking - with her full recovery after her cardiac arrest last February.

Why does someone's heart suddenly stop beating? Cardiac arrest is often caused by a blockage (or blockages) in the arteries feeding the heart -- better known as coronary artery disease -- but it also can happen as a result of other heart and lung problems or stroke. When the heart stops, the brain and other organs lose their blood supply, making quick resuscitation essential. But when the oxygen-rich blood rushes back into the brain, it can be a damaging shock to the already fragile tissue. Even if patients regain consciousness, they often need nursing care or other forms of assistance for the rest of their lives.

Now, a newer procedure called therapeutic hypothermia -- practiced at The Chester County Hospital and just a fraction of all hospitals nationally -- is improving the odds of successful recovery after cardiac arrest for patients who have been resuscitated but remain in a coma. This therapy cools the body to 92 degrees Fahrenheit, or roughly six degrees lower than normal body temperature, and maintains it there for 24 hours. This slows down destructive inflammatory processes to give the brain tissue time to recover gradually.

"You can think of it as cooling the body to save the brain," says Susan Savini, CRNP, Director of Critical Care Nurse Practitioners at the Hospital. "People can survive cardiac arrest, but if you don't take care of those brain cells, what quality of life will they have? We've always known that putting something cold on an injury can be helpful: Think of your mom telling you to put ice on a sprain, or how in the past it was discovered that injured soldiers healed better in the cold than when they were laying right by the fire."

In 2002, two landmark studies showed that when patients were cooled after cardiac arrest, they had about a 20% greater likelihood of surviving with brain function intact. Later studies suggested that for some groups of patients, the improvement was even more dramatic. By 2005, the American Heart Association (AHA) began recommending therapeutic hypothermia as the standard of care for selected patients after cardiac arrest -- especially those who had a cardiac event that caused a specific type of arrhythmia (irregular heartbeat) known as ventricular fibrillation. (Some patients are not good candidates, such as those who have had recent surgery, have bleeding disorders or other health complications, or are pregnant.)

HypothermiaWhen a patient is being cooled, it is imperative to monitor him closely. Together as a team (from left), intensivist John Wang, MD, Susan Savini, CRNP, Sarah Riddle, RN, and Michelle Root, RN (with back to the camera), carefully decrease the cardiac arrest patient's body temperature to 92 degrees Fahrenheit using a hypothermia machine (bottom Left) and padded wraps.

Physicians and nurses at The Chester County Hospital were following these developments with great interest when intensivist John Wang, MD, joined the Hospital's group of full-time Intensive Care Unit (ICU) physicians in early 2007. Both he and fellow intensivist Don Emery, MD, previously worked at the same hospital where they had experience using therapeutic hypothermia.

"When I had my first post-cardiac arrest patient here, I wanted to use the therapy, so we cooled manually with cold packs and ice packs," Dr. Wang recalls. "This piqued everyone's interest even more, and we all decided this was something we wanted to be able to offer here in this community."

The Hospital soon purchased a hypothermia machine, a mobile unit with several cooling blankets and pads that are placed on a patient's body to cool it to the target temperature. Dr. Wang and the entire Critical Care group surveyed other hospitals' practices and began developing the Hospital's own therapeutic hypothermia protocol -- a step-by-step guide that includes everything from how to decide whether a patient is an appropriate candidate, to what medications to give and vital signs to monitor, to how long to cool and then rewarm.

By the end of 2007, the ICU staff had mastered the process and began rolling it out to other departments, including the Emergency Department (ED), which soon had its own dedicated cooling machine, and the Cardiac Catheterization Laboratory (cath lab). Their involvement is critical because research now suggests that getting therapeutic hypothermia started as soon as possible is more beneficial than waiting until the patient is moved up to the ICU. It also requires an extraordinary level of cooperation among all three disciplines, as well as other departments such as respiratory therapy and imaging. In a 2010 inter view with Reuters, an expert with Penn's Center for Resuscitation Science suggested that only about one-fourth of hospitals nationwide offer therapeutic hypothermia because such cross-disciplinary coordination is simply too great a barrier.

"Certainly there had to be some discussion about how exactly we were going to do this," says ED physician Dudley Backup, MD. "For instance, we had to consult with the cardiologists about what was going to take place and when. You don't want to delay the cooling, but many of these patients also need to get to the cath lab quickly for treatment.

"We have all been committed to offering this because it is the kind of state-of-the-art care you would want your own family member to have," he adds. "There is compelling data showing that this is their best hope. And you don't want to have to transfer a patient out and lose precious time because you can't offer it."

Today, therapeutic hypothermia is initiated in the ED, and the cooling equipment can move with patients who need to go to the cath lab. There, cardiologists focus on opening up the blockage that led to cardiac arrest, while the intensivists continue with the cooling protocol.

"It really is a seamless process," notes Timothy Boyek, MD, Director of the Cardiac Catheterization Lab. "Just as the EMTs in the field activate us to get ready for the patient, they let the ED know they have a cardiac arrest patient and the ED notifies the intensivists. The hypothermia protocol does not slow us down. We stay focused on opening up the artery as quickly as possible, but the cooling doesn't have to stop.

"The AHA now has a national initiative to develop hypothermia programs across the country," adds Dr. Boyek, who actively participates in Pennsylvania's efforts related to AHA's Mission Lifeline, a project focused on giving evidence-based care to all heart attack patients. "The Hospital is far ahead of the game, thanks in large part to the intensivists driving this effort. Ten or 20 years ago, you might fix the blockage that caused the arrest but the person would die anyway, or never be the same again. So this new therapy is really pivotal."

Since April 2009, the Hospital has treated approximately 15 post-cardiac arrest patients with therapeutic hypothermia. ICU nurse Christine M. Parsons, RN, BSN, has cared for several of them. She notes that these patients require very close monitoring of their blood pressure, temperature and other vital signs as they are cooled and then again during the rewarming process.

HypothermiaMembers of the ICU Team (from left): Susan Savini, CRNP; John Wang, MD; Renee Giometti, MD; Donald Emery, MD; John Roberts, MD; Kristen Shiban, CRNP; and Minnie Abraham, CRNP.

"At times you need to take vital signs every 15 minutes, so really you're working with this patient one-to-one," she says. "But I think the most challenging part is supporting the family. They've already seen this person they love go through cardiac arrest and come so close to death. Now they have to wait about 48 hours or more to find out whether this person is ultimately going to live. It's just a very trying period for the family.

"As a care team, we all work to reassure the family that the patient is in good hands, and we have the equipment and the process here that has been proven to offer the best chance of a full recovery," she adds.

If a patient pulls through, it can be several days to even months before anyone knows how well the brain has recovered. So far, though, there have been some great success stories at the Hospital. Parsons says there was a patient recently who woke up, quickly recognized his family members, and walked with assistance in three days. Another patient just returned for a friendly visit two months after her release from the ICU and reported that she was swimming again, going to the gym, and back to her normal routine. "Seeing a patient like that come back is incredibly rewarding and encouraging," Parsons says.

As the Hospital continues to treat patients with therapeutic hypothermia, the team will continue to make changes to its protocols and care processes as needed. Another key goal is getting the cooling process started even sooner for the right patients by EMTs in the field. Dr. Backup of the ED, who directs three local Emergency Medical Services units, says that two are already able to cool in the field using cold packs and chilled IV fluids. Dr. Ian Butler, an intensivist who recently joined the ICU staff, is also working with other local EMS teams to get the word out and help make pre-hospital therapeutic hypothermia a standard across Chester County.

"It is certainly exciting and rewarding to offer this expert level of care in our community hospital," says Maureen Sutcliffe, RN, BSN, CEN, Clinical Manager of the ED. "We see this as an opportunity in which we can quite possibly save a patient who comes to us in very serious condition. Although cooling never guarantees recovery, we welcome this chance to make a difference in the lives of some critically ill patients and their loved ones."

* Source: The New England Journal of Medicine
** Source: American Heart Association


By Kristine M. Conner
Photo by Rick Davis

Last Updated: 11/28/2011