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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