Hypothermia treatment protocol - AANN
1) Consider using therapeutic normothermia for all patients who are neurologically impaired, mechanically ventilated, and have a core body temperature greater than 37.80 C (1000 F).
2) All patients must be admitted to the Neuro Critical Care Unit (NCCU)
3) Patient resources include:
a) Essential
i) Standard ICU monitoring
ii) Salem sump tube
iii) Foley catheter
iv) Medi-therm III Hypothermia machine with 2 sets of hoses and one set of Rapr-Round wraps (Torso and Legs x 2)
v) T/Pad and T/Pump
vi) Foley with termister or Esophageal temperature probe
vii) BIS monitor
b) Optional
i) CVP or PA catheter (preferably positioned in the Subclavian Vein)
ii) Arterial pressure line
4) Patient monitoring
a) Continuous
i) Cardiac monitor
ii) Oxygen saturation
iii) BIS monitor
iv) Blood pressure via arterial line (optional)
b) Every 1 hour
i) Core temperature
ii) Shiver assessment (see protocol below)
c) Every 2 hours
i) Finger stick glucose
1) If glucose > 140 mg/dl, initiate IV insulin protocol and convert to hourly finger stick glucose monitoring
5) Surface Cooling for intubated patients
a) Endotracheal intubation and mechanical ventilation
i) Assure appropriate endotracheal tube placement per standard protocol
ii) Ventilator setting as appropriate for the patient’s presenting condition
b) Induction of shivering suppression protocol
i) Shiver is a MAJOR clinical issue in active normothermia maintenance. Each patient should be observed closely for shiver. In addition to visual monitoring, the nurse should gently palpate the patient’s masseters (jaw), pectoralis, and deltoids every 30 to 60 minutes. In addition, fine fluctuations on the patient’s cardiac rhythm tracing may also indicate shiver.
ii) Subsequent shiver suppression should be based on the Columbia Shiver Assessment Scale (CSAS). Assess and record the patient’s CSAS every 30 – 60 minutes and prn. Palpate the following muscle groups – massiters (jaw), pectoralis, deltoids, and quadriceps.
0 – no shiver
1 – MILD = shiver in jaw and/or pectoralis, or cardiac rhythm tracing
2 – MODERATE = shiver in jaw and/or pectoralis AND deltoids
3 – SEVERE = intermittent generalized shiver of > 2 extremities
1) Interventions for shiver suppression should be step-wise and based on the CSAS
0 – No Shiver
Optimize sedation and analgesia
Propofol (Diprivan) drip
Fentanyl drip
Alter shiver threshold
Buspirone (BusPar) by gastric tube
1 – MILD
Optimize sedation and analgesia
Propofol (Diprivan) drip
Fentanyl drip
Alter shiver threshold
Buspirone (BusPar) by gastric tube
Vasodilatation
Magnesium drip
Increased comfort measures
Hand and feet warmers
2 – MODERATE
Optimize sedation and analgesia
Propofol (Diprivan) drip
Fentanyl drip
Alter shiver threshold
Buspirone (BusPar) by gastric tube
Meperidine (Demerol) IV bolus
Vasodilatation
Magnesium drip
Increased comfort measures
Hand and feet warmers
3 – SEVERE
Optimize sedation and analgesia
Propofol (Diprivan) drip
Fentanyl drip
Alter shiver threshold
Buspirone (BusPar) by gastric tube
Meperidine (Demerol) IV bolus
Vasodilatation
Magnesium drip
Neuromuscular blockade
Vecuronium (Norcuron) intermittent boluses
Increased comfort measures
Hand and feet warmers
2) Specific instructions for the interventions above
a) Propofol (Diprivan) (to provide shiver suppression and continuous sedation)
i) Continuous infusion at 20 mcg/kg/min
1. Titrate by 5-10 mcg/kg/min every 10 minutes
2. Maintain BIS reading of 40 – 60
b) Fentanyl (adjunctive therapy for shiver suppression and sedation)
i) Bolus 50 mcg IV push and repeat every 30 minutes until the continuous infusion is initiated
ii) Continuous infusion at 2 mcg/kg/hour
c) Buspirone (BusPar) (pharmacologically lowers the shiver threshold)
i) Initial dose 30 mg by gastric tube
ii) Then, 15 mg by gastric tube every 8 hours until rewarmed to 360 C (96.80 F)
d) Meperidine (Demerol) (pharmacologically lowers the shiver threshold and is synergistic with buspirone)
i) 25 mg IV bolus x 1, then
ii) 12.5 mg IV bolus every 30 minutes PRN
e) Magnesium drip (vasodilatation – improves efficacy of cooling and increases patient comfort)
i) Prepare 12 grams Magnesium Sulfate in 250 mL of normal saline
ii) Continuous infusion at 10 mL/hr (0.5 g/hr)
iii) Titrate to maintain a serum magnesium level of 3 – 4 mg/dL
iv) Monitor serum magnesium levels every 6 to 12 hours
f) Vecuronium (Norcuron) (only AFTER adequate sedation achieved – BIS < 60)
i) Bolus 0.1 mg/kg x 1
ii) Re-bolus Vecuronium prn shivering
g) Hand and feet warmers (improves subjective patient comfort)
i) Hand
1. Place one warm compress (chemical pack) in each hand. Secure to hand with stockinette if needed
2. Change prn
ii) Feet
1. Place T/Pad over and around feet
2. Connect to T/Pump
3. Set T/Pump to 380 C (100.40 F)
6) Normothermia induction and maintenance – see below
|Normothermia induction and maintenance |
|Place esophageal or bladder continuous temperature probe |
|Torso wrap |
|Apply Torso wrap directly on the patient |
|Place a patient gown OVER the body wrap |
|Leg wraps |
|Apply leg wraps to the patient’s legs |
|Place SCDs over the wraps |
|Therapy induction |
|If initial core temperature > 390 C (102.20 F) |
|Infuse cold NS (40 – 60 C / 390 – 430 F) |
|1000 mL x 2 over 10 minutes each (use a pressure bag) |
|If core temperature reaches 370 C (98.60 F), discontinue cold NS infusion |
|If after the second bolus of cold NS, the core temperature remains > 370 C (98.60 F) |
|Give an additional volume of cold saline, also on a pressure bag, to make a final volume of 40 mL/kg |
|If initial core temperature > 37.80 and < 390 C (100 - 102.20 F) |
|Infuse cold NS (40 – 60 C / 390 – 430 F) |
|1000 mL x 1 over 10 minutes (use a pressure bag) |
|If core temperature reaches 370 C (98.60 F), discontinue cold NS infusion |
|If after initial 1000 mL bolus, the core temperature remains > 370 C (98.60 F) – administer an additional 1000 mL cold NS x 1 over |
|10 minutes (use a pressure bag) |
|If after the second bolus of cold NS, the core temperature remains > 370 C (98.60 F) |
|Give an additional volume of cold saline, also on a pressure bag, to make a final volume of 40 mL/kg |
|Interrupt cold NS infusion if CVP increases greater than 5 mmHg over 5 minutes. Restart when volume status stabilizes. |
|Connect the temperature probe to the Medi-therm III Cooling Machine and set on AUTO – RAPID Mode and the Set-Point = 360 C (96.40 |
|F) |
|Therapy maintenance |
|Maintain the set-point setting of 360 C (96.40 F) until clinical concern for fever has resolved |
|Termination of active normothermia |
|Once the clinical concern for fever has resolved |
|Set the machine to monitor |
|Leave the wraps on the patient |
|Continuously monitor temperature for at least 24 hours |
|If core temperature exceeds 380 C (100.40 F), resume active normothermia protocol as above |
Columbia Shiver Assessment Scale (CSAS)
0 – no shiver
1 – MILD = shiver in jaw and/or pectoralis, or cardiac rhythm tracing
2 – MODERATE = shiver in jaw and/or pectoralis AND deltoids
3 – SEVERE = intermittent generalized shiver of > 2 extremities
Interventions based on CSAS
0 – No Shiver
Optimize sedation and analgesia
Propofol (Diprivan) drip
Fentanyl drip
Alter shiver threshold
Buspirone (BusPar) by gastric tube
1 – MILD – all interventions above and ADD
Vasodilatation
Magnesium drip
Increased comfort measures
Hand and feet warmers
2 – MODERATE – all interventions above and ADD
Alter shiver threshold
Meperidine (Demerol) IV bolus
3 – SEVERE – all interventions above and ADD
Neuromuscular blockade
Vecuronium (Norcuron) intermittent boluses
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