CRITICAL CAREPOLICY AND

PROCEDURE MANUALPage 1 of 10

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Title: Adult Therapeutic Hypothermia Policy No. CC-8.03

Joint Commission Chapter/Section: Effective Date: June, 2014

Source (e.g. document, award, or committee, etc.)A. Bukhari, MD, Chief, Pulmonary, Critical CareCritical Care Committee

Publication Status: New X Revised8/13 Reviewed

Cross-Referenced Policy No: Neuromuscular blockade CC-14.01

I. POLICY:

The “Code Chill” protocol will be activated upon identification of a patient who is a potentialcandidate for the application of Adult Therapeutic Hypothermia Post Cardiac Arrest. Theorder will be provided by an attending physician who is called upon to evaluate a patient in theEmergency Department or adult inpatient areas.

II. PURPOSE:

This policy defines the procedure for the application of Adult Hypothermia Post CardiacArrest. The patients must fit the inclusion and exclusion criteria as defined in the proceedingbody of this document.

III. SCOPE:

The scope of this policy includes the Emergency Department, Adult ICU and licensedindependent practitioners.

IV. DEFINITIONS:

A. ADULT THERAPEUTIC HYPOTHERMIA

Hypothermia is a state of body temperature below normal in a homoeothermic (warm-blooded) organism. Therapeutic hypothermia is administered in a controlled way, as incontrast to accidental hypothermia. With controlled hypothermia, it is possible to avoidpossible defense mechanisms like shivering or catecholamine release.

The multifactorial protective action of hypothermia includes the protection of lipidmembranes fluidity, the slowing of destructive enzymatic processes and the reductionof oxygen needs without impairing microvasculatory blood flow in low-flow regionsduring reperfusion after ischemia. Additionally, therapeutic hypothermia inhibits lipidperoxidation, attenuates brain edema, and reduces intracellular acidosis

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Cold saline is defined as 0.9% sodium chloride IV at a temperature range from 36 to 46degrees F for therapeutic hypothermia. The cold saline is stored in a medication refrigerator.

B. CODE CHILL TEAM MEMBERS

Code Chill employs a collaborative approach whose team members can include:

In the Emergency Department:ED physician and Licensed Independent Practitioner (LIP)ED Nursing TeamED Manager or Nursing supervisorRespiratory therapistICU resident and/or Critical Care Attending

In the Adult ICU:ICU Resident and/or Critical Care AttendingICU NurseICU Assistant Nurse Manager, or Charge nurseICU Manager or Nursing supervisorRespiratory therapist

C. POPULATION OR CLINICAL CONDITION

Inclusion Criteria: All criteria must be met.Patient age between 18 to 75 years of ageReturn of Spontaneous Circulation (ROSC) within 60 minutes of starting CPRMechanically ventilatedComatose/unresponsive to commands/ no purposeful movement(Glascow coma scale less than 8)

Exclusion Criteria: One (or more) criteria must be met.Pulseless greater than 60 minutesDNR statusMajor head traumaCoagulopathyUncontrolled hemodynamically significant dysrhythmiaHistory of cryoglobulinemiaGreater than 6 hours lapsed from time of return of spontaneouscirculation (ROSC).

Relative Contraindications:PregnancyMajor surgery within 14 daysBaseline cognitive function severely impairedEnd stage terminal illnessMulti organ dysfunctionSepsis prior to cardiac arrest

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V. PROCEDURE:

The ED Attending Physician/Critical Care Attending will:1. Evaluate the patient for eligibility.

The ED RN/ICU RN will:1. Initiate Code Chill protocol

A. In The Emergency Department (ED) Setting1. The ED staff will evaluate the patient for eligibility for cooling therapy.2. If eligible the Code Chill protocol will be initiated by calling 112, which

will send an overhead page in which the operator will state “Code Chill”and identify the location.

3. The overhead “Code Chill” promptly secures an ICU bed for the patient.4. Appropriate ICU personnel will respond to “Code Chill” in the ED.5. The ED staff will initiate cooling protocol with cold saline and ice packs

as per orders. Ensure that there is a barrier between the skin and the icepacks to prevent skin injury. Remove the ice packs once the goaltemperature is reached.

6. The ED nurse will conduct a thorough skin assessment on arrival toidentify potential deep tissue injury or other pressure areas present uponadmission and document findings.

7. The ED provider will determine if patient requires emergent cardiacintervention; if so, the team initiates the CODE MI protocol.

B. Cardiac Catheterization Lab1. Continue cooling protocol if already initiated

C. Intensive Care Unit ( ICU)

Initial Cooling Phase (Use the Gaymar Medi-Therm III MTA 7900):1. Once hypothermia eligibility is confirmed, and hypothermia orders are

obtained from the physician, gather the following materials.Internal temperature monitoring device by rectal probe.Approved cooling devicePeripheral nerve stimulatorNasogastric tubeLubricant60 ml catheter-tip syringeRectal thermometerLine cart for central line &/or arterial line insertionCold normal saline as ordered. Obtain cold saline frommedication refrigerator.

2. Insert two (2) peripheral large bore IVs, 18 gauge or larger, as ordered ifa central line is not present, as ordered.

3. Obtain baseline temperature and follow all monitoring parameters asordered for TH on the TH Flow Sheet in the including: vital signs, coretemperature, oxygen saturation, urine output and shivering scale.

4. Sedation is initiated and titrated to prevent shivering prior to applicationof cooling management system per the sedation order set (Form #) andthe orders of the LIP.

5. Obtain laboratory specimens ordered. Alert the lab that the patient is a“Code Chill” patient and that the ABG is to be tested at the patient’stemperature at the time the ABG was drawn.

6. Suspend all attempts at ventilator weaning during the cooling and re-warming phases of Code Chill.

7. Infuse cold normal saline IV as ordered.

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8. Initiate surface cooling device and attached cooling wraps on lowerextremities and trunk of the body per manufacturer’s instructions.

9. Activate cooling system with temperature set to 33 degrees C (91.4F)as goal temperature. Utilize additional surface cooling devices asappropriate to reach target temperature.

10. Set thermostat in the patient’s room to 65 degrees F during TH.11. Respiratory therapist should turn temperature on ventilator heater to off

and use a moisture exchange filter.12. Monitor and document vital signs per protocol (every 15minutes for 1

hour then every 30 minutes for 2 hours then per ICU protocol. Monitorfor arrhythmias (most common bradycardia). If significant dysrhythmias,hemodynamic instability or bleeding develops, MD should be notifiedimmediately.

13. RN will perform hourly assessments of skin integrity & catheter sites,assess for signs of tissue intolerance. Skin will be assessed under thepads every 4 hours (open wraps to fully assess skin).

14. Document and trend water temperature hourly15. Maintain cooling process for any patient transports.

Immediately reportable conditions during hypothermia:DysrhythmiasSeizureBleedingA QT interval greater than 500 milliseconds (0.5 seconds) or anincrease in the QT interval of 60 milliseconds (0.06 seconds)from the patient’s baseline QT interval.

D. Management to Prevent / Control Shivering: Refer to Policy CC-14.01(Antianxiety, Analgesic & Paralytic use)

1. If paralytic is ordered for management of shivering prior toadministration, an order must be obtained for sedation.

2. Follow the orders in the Analgesic and Paralytic order set.3. Attempt to titrate paralytic off when goal of 33 degrees C (92 degrees F)

is reached per policy if the patient is not shivering.

Rewarming Phase1. When patient reaches set goal of 33 degrees C (92 degrees F) for 24

hours begin rewarming at 0.3 degree C/hour (0.54 degrees F/hour) notto exceed greater than 1 degree C /hour) to target goal. Use the“Moderate” setting on the Gaymar Medi-Therm III MTA 7900 machine.

2. Keep probe in place and surface garments on until patient isnormothermic; then titrate per sedation/analgesia protocol.

3. Turn on ventilator heater and set to 37 degrees Celsius (98.6 degreesFahrenheit).

4. Maintain normothermia for an additional 24 hours once patient’s coretemperature reaches 36 degrees Celsius (96.8 degrees Fahrenheit). Ifthe patient’s temperature is equal to or greater than 37.5 degrees Celsius(99.5 degrees Fahrenheit), notify the LIP for further orders.

DOCUMENTATION1. Initiation, ongoing and termination of protocol.2. Baseline and hourly patient temperature and route on the hypothermia therapy flow

sheet.3. Trend water temperature4. Presence of shivering5. Skin Integrity

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VI. REFERENCES:

Holzer, Micheal, and Behringer, Wilhelm, Therapeutic hypothermia after cardiac arrest andmyocardial infarction, Best Practices & Research Clinical Anesthesiology, vol. 22, No. 4, pp.711-728, 2008. doi:10.1016/j.bpa.2008.02.001, available online athttp://www.sciencedirect.com.

Morris, S. (2011). 2010 BLS and ACLS Guideline Changes: Post-Cardiac Arrest Syndromeand Therapeutic Hypothermia. Canadian Journal of Cardiovascular Nursing, 21 (3), 3-5.Young-Min, K., Hyeon-Woo, Y., Seung-Hee, J., Mary Lou, K., & Clifton WC. (n.d.). Clinicalpaper: Does therapeutic benefit adult cardiac arrest patients.

Wang, C., Yang, S., Lee, C., Lin, R., Peng, M., & Wu, C. (2013). Therapeutic hypothermiaapplication vs. standard support care in post resuscitated out of hospital cardiac arrest patients.American Journal of Emergency Medicine, 31 (2), 319-325.doi:10.1016/j.ajema.2012.08.024.

Approved by:CNO/Vice President –Patient Care Services 6/4/14

Signature - Elizabeth Wykpisz, RN,MSN, MBA, NEA-BC

Title Date

Director, Critical Care & AdultMed/Surg 6/4/14

Signature –Sharon Haskins, MSN,MBA, RN-BC, NE-BC

Title Date

Origination Date: 4/18/2013Supersedes Date(s): 6/4/14Reviewed Date:Revised Date: 5/2014

CC-8.03

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