NEW YORK NURSE: January-February 2011
by Christopher Kowal, BS, MSN-MOL-ED, RN, CCRN-CMC-CSC Staff Nurse, Surgical Intensive Care Unit, St. Joseph's Hospital health Center
Targeted temperature management (TTM; Peberdy, Callawy, Neumar, Geocadin, Zimmerman, Donnino et al., 2010), also known as therapeutic hypothermia (TH), is an induced state of cooling the human body in order to preserve brain function and promote complete organ stasis following return of spontaneous circulation (ROSC) after cardiac arrest (Federico, 2010; Peberdy et al., 2010). Implemented early in the unconscious, post-cardiac resuscitation patient, purposefully induced hypothermia will reduce the risk of brain ischemia, improve neurologic outcomes, and decrease mortality (Federico, 2008; Peberdy et al., 2010; Varon & Acosta, 2008).
TH dates back well-before ancient times (Federico, 2010), but is seen more in the literature since the late 1700s (Varon & Acosta, 2008). In Russia, people were covered with snow in the hopes that spontaneous circulation would return (Varon & Acosta, 2008). Napolean’s battlefield surgeons remarked that soldiers seemed to have better survival rates if they were left outside in the cold rather than warmed up (Federico, 2010). Documented clinical research in head trauma and cardiac bypass surgery patients in the 1950s (Federico, 2010) began to show that TH was beneficial to neurological recovery.
TTM slows metabolism. Regarding brain function, a person’s brain oxygen expenditure, glucose utilization, and lactate concentration are driven by the body’s temperature. TH has been shown to slow brain metabolism by 7 percent by reducing each of these levels (Varon & Acosta, 2008).
Early intervention with TH is the key to achieving winning results in likely candidates because it will yield more positive results. Speed of initiation and re-warming, duration, and side effect management are integral to positive outcomes (Federico, 2010).
Contraindications to TH are specific. They include: patients that follow commands, more than 8 hours has elapsed since ROSC, life-threatening bleeding or infection occurs, cardiovascular collapse is impending, or the patient suffers from an underlying terminal condition (Seder & Van der Kloot, 2009).
TH duration is at least 12-hours, but studies have shown that it may approach 24 hours plus (Peberdy et al., 2010). In addition to the specific TH protocol, further interventions (Federico, 2010) integral to nursing include monitoring arterial blood gas (ABG), consciousness, sedation, and shivering levels. Hypothermia puts patients at added risk for acidosis, electrolyte abnormalities, EKG changes, altered consciousness, spontaneous diuresis, discomfort, and body shakes (Arpino & Greer, 2008).
According to Peberdy (2010), additional complications related to TTM involve coagulopathy, hyperglycemia, pneumonia, sepsis, and decreased immunity. Patients are at greater risk for experiencing these complications if TH is prolonged or temperature is below the range for a long time (Peberdy et al., 2010).
More research in TTM is still necessary, but there is enough to recommend that guidelines be utilized more in hospitals throughout the US. Many facilities still do not carry out this lifesaving method of recovery either due to lack of awareness, unwillingness to accept it, or financial constraints (Federico, 2010).
Widespread education and dissemination of better practice is necessary to perpetuate and maintain improved outcomes in healthcare. Nursing has a duty to assist in spreading new information like TH to encourage awareness and a movement towards change. More appropriate utilization of TTM promotes better-quality results in care (Federico, 2010).
Arpino, P. A., & Greer, D. M. (2008). Practical pharmacologic aspects of therapeutic hypothermia after cardiac arrest. Pharmacotherapy, 28(1), 102-111. Available from http://www.medscape.com
Federico, A. (2010). Therapeutic hypothermia: A case study. Journal of PeriAnesthesia Nursing, 25(3), 141-145. doi:10.1016/j.jopan.2010.03.011
Holden, M., & Makic, M. B. (2006). Clinically induced hypothermia: Why chill your patient? American Association of Critical Care Nurses Advanced Critical Care, 17(2), 125-132.
Peberdy, M. A., Callaway, C. W., Neumar, R. W., Geocadin, R. G., Zimmerman, J. L., Donnino, M.,…Kronick, S. L. (2010). Part 9: Post-cardiac arrest care. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122(Suppl. 3), S768-S786. doi:10.1161/CIRCULATIONAHA.110.971002
Seder, D. B., & Van der Kloot, T. E. (2009). Methods of cooling: Practical aspects of therapeutic temperature management. Critical Care Medicine, 37(7 Suppl), S211-222. doi:10.1097/CCM.0b013e3181aa5bad
Varon, J., & Acosta, P. (2008). Therapeutic hypothermia: Past, present, and future. Chest, 133(5), 1267-1274. doi:10.1378/chest.07-2190