Discussion of therapeutic hypothermia for cardiac arrest.

1. Therapeutic Hypothermia
Frank W Meissner MD, FACP, FACC, FCCP, FASNC

2. The Hidden Obstacle to Reanimation
CNS Reperfusion Injury
Simply defined as ‘damage observed
after resoration of blood flow to ischemic
tissues’

3. Hypoxic Cerebral Insult
6% Decrease in Cerebral Metabolism per
1°C Decrease Core Body Temp => Anti-
inflammatory Effects
Resultant Suppression Of CNS Reperfusion
Injury
Decreased Free Radical Production
Reduced Excitatory Neurotransmitters
Suppression of Ca++ mediated cell death

4. Proof of Theory Studies

5. HACA* Study Group
Witnessed Cardiac Arrest (VF ^ VT)
Age 18-75 yr
Est time Reanimation attempt 5-15 min
ROSC ≤ 60 mins
275 of 3,551 Arrests Met Inclusion Criteria
137 Randomized to Hypothermia
Body Core Temperature 32-34° C X 24 hr
Rewarmed over 8 hr
* Hypothermia After Cardiac Arrest

6. Principle Results I
Cumulative Survival in the Normothermia and Hypothermia Groups
The Hypothermia after Cardiac Arrest Study Group, . N Engl J Med 2002;346:549-556

7. Principle Results II
The Hypothermia after Cardiac Arrest Study Group, . N Engl J Med 2002;346:549-556

8. Current AHA (Y2005) Guideline
Unconscious adult patients with ROSC after
out-of-hospital arrest cooled to 32 - 34 °C
(89.6 - 93.2° F) X 12-24 hr in V Fib
Arrest(Class IIa)
Similiar therapy may be beneficial for out-of
hospital or in-hospital non-VF arrest (Class
IIb)

9. Optimal Therapy

10. Surface Cooling I
Conventional Surface Cooling (circulating cold water blankets or cold air-forced blankets) can take 4-8 hrs to
reach 32-34° and temperature titration can be difficult CritiCool System uses 3-D CureWrap™ one piece garment
with temperature controller resulting in high efficiency precisely controlled external cooling

11. Surface Cooling II
Advantages
Application in 2 minutes
Portable no power requirements
High Cooling Capacity
Radioluminescent
User friendly
Suitable for induction and maintenance of cooling
Low investment costs

12. Medivance Arctic Sun™
Patented Design
Arctic Sun and
ArcticGel™ Pads
enables transfer of
up to five times
more thermal
energy than
conventional
methods such as
water blankets,
wraps or ice packs.
System’s precision
enables slow
rewarming thought
to be critical for
therapeutic benefit.
The Arctic Sun has
received 510(k) FDA
clearance in the
U.S.

13. Blanketrol™ III

14. Invasive Cooling Methods I
30ml/kg Lacated Ringers Solution @ 4°
C infused via femoral catheter over 30
mins => T 35.5 to 33.8° C
Rapid & predictable + volume infusion
blunts hypothermia induced diuresis
Maintenance therapy cooling blankets
Bernard, S. et al. Induced hypothermia using large volume, ice-cold intravenous fluid in comatose
survivors of out-of-hospital cardiac arrest: A preliminary report. Resuscitation 2003;56:9-13)

15. Invasive Cooling Methods II
Shivering blunts
external cooling
efforts unless
moderated by
Propofol or
Benzo’s
Zoll (Formerly Alsius)
Thermogard XP System

16. Thermal Regulatory Performance
Cincinnati
Medeco
Icy Catheter Arctic Sun Subzero Conventional
Caircooler
Blanketrol III
External H20
Cooling IV Heat External Gel- External Air Cold Saline, Ice,
Circulating Circulating Pads
Method Exchange coated Pads bags, Etc.
Pads
Cooling Rate
(°C) 1.46 1.04 1.33 0.18 0.32
% of time Temp
out of range
(>0.2 °C from 3.2 44.2 50.5 74.1 69.8
Target Temp)
Hoedemaekers CW, et al. Comparison of different cooling methods to induce and maintain normo- and
hypothermia in ICU patients: a prospective intervention study. Critical Care 2007; 11:R91.

17. Invasive Cooling III
Zoll Catheter Systems

18. Invasive Cooling IV
Zoll Catheter Systems

19. Practical Approach
Induction Phase (within 4 hr of arrest)
Cold IV Saline
NG Iced Lavage
Cold Packs in Groin & Axilla
Maintenance Phase (12 to 24 hr)
IV Cooling Catheter
External Cooling Patches or Arctic Sun System
Rewarming Phase (Precise Temp Control VITAL)
0.25 - 0.5 ° C/hr

20. Financial Analysis
Avg Avg Direct
Avg Direct
Revenue Margin Per
Cost Per Pt
Per Pt Pt
Discharged
$57,783 $37,099 $20,684
Alive
Expired in
$12,014 $8,686 $3,329
Hospital
Take Heart America Program
St Cloud Minn - Dec 05- Nov 07

21. Financial Analysis
On average, each SCA patient delivered
alive to ED generated $27,900 of
revenue & $9,400 of direct margin
regardless of outcome in the hospital

22. Financial Analysis
St Cloud saw a 131% increase in arrest
survival rate compared to previous year
=> $1,088,000 additional hospital
revenue with direct margin of $366,000
over 19 month period of the study

23. Knowledge Transition
HACA Theory Into Practice
Europe & USA 30-40%
Implementation of therapeutic hypothermia
guidelines for post-cardiac arrest syndrome at a
glacial pace: Seeking guidance from the
knowledge translation literature
Resuscitation - Volume 77, Issue 3,
Pages 286-292 (June 2008)

24. Barrier’s To Implementation
500% variation in post arrest survival
Therapeutic Nihilism & Fatalism
Stove-piped Processes
Inability To Effectively Team
Lack of Physician Champion
Institutional Financial Concerns

25. Level I Cardiac Arrest Center
Minimum of 40 reanimated patient’s
annually
Aligned with STEMI Primary PCI
Treatment of re-arrest
EP assessment and/or ICD assessment
and implantation

26. Roadmap