Sudden cardiac death is the most common cause of death in the United States. Despite aggressive resuscitation, only one tenth to one third of successfully resuscitated patients survive to lead an independent life. Although evidence clearly supports the use of induced therapeutic hypothermia post–cardiac arrest, the precise data on how to best implement this process is still forthcoming. Protocol-based treatment regimens have been shown to improve morbidity and mortality of patients with common ICU illnesses. This article discusses the multiple elements compromising therapeutic hypothermia and presents recommendations for a protocol-driven regimen that can be implemented across varied critical care settings.
KongMHFonarowGCPetersonED. Systematic review of the incidence of sudden cardiac death in the United States. J Am Coll Cardiol. 2011;57:794-801.
2.
ArrichJHolzerMHerknerJMüllnerM. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev. 2009;(4):CD004128. doi:10.1002/14651858.CD004128.pub2.
3.
BernardSAGrayTWBuistMD. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346:557-563.
4.
Hypothermia After Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346:549-556.
5.
NolanJPNeumarRWAdrieC. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication: a Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation. 2008;79:350-379.
6.
HasibederWR. Does standardization of critical care work?Curr Opin Crit Care. 2010;16:493-498.
7.
KirvesHSkrifvarsMBVahakuopusMEkstromKMartikainenMCastrenM. Adherence to resuscitation guidelines during prehospital care of cardiac arrest patients. Eur J Emerg Med. 2007;14:75-81.
8.
SundeKPytteMJacobsenD. Implementation of a standardized treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation. 2007;73:29-39.
9.
ArrichJ. Clinical application of mild therapeutic hypothermia after cardiac arrest. Crit Care Med. 2007;35:1041-1047.
10.
HolzerMMullnerMSterzF. Efficacy and safety of endovascular cooling after cardiac arrest: cohort study and Bayesian approach. Stroke. 2006;37:1792-1797.
11.
BernardSAJonesBMHorneMK. Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest. Ann Emerg Med. 1997;30:146-153.
12.
OddoMSchallerMDFeihlFRibordyVLiaudetL. From evidence to clinical practice: effective implementation of therapeutic hypothermia to improve patient outcome after cardiac arrest. Crit Care Med. 2006;34:1865-1873.
13.
NolanJPMorleyPTVanden HoekTLHickeyRW. Therapeutic hypothermia after cardiac arrest: an advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation. Circulation. 2003;108:118-121.
14.
HolzerMBernardSHachimi-IdrissiSRoineRSterzFMarcusM. Hypothermia for neuroprotection after cardiac arrest: systematic review and individual patient data meta-analysis. Crit Care Med. 2005;33:414-418.
15.
SkulecRKovarnikTDostalovaGKolarJLinhartA. Induction of mild hypothermia in cardiac arrest survivors presenting with cardiogenic shock syndrome. Acta Anaesthesiol Scand. 2008;52:188-194.
16.
HolzerM. Targeted temperature management for comatose survivors of cardiac arrest. N Engl J Med. 2010;363:1256-1264.
17.
KimJJYangHJLimYS. Effectiveness of each target body temperature during therapeutic hypothermia after cardiac arrest. Am J Emerg Med. 2011;29:148-154.
18.
KuboyamaKSafarPRadovskyATishermanSAStezoskiSWAlexanderH. Delay in cooling negates the beneficial effect of mild resuscitative cerebral hypothermia after cardiac arrest in dogs: a prospective, randomized study. Crit Care Med. 1993;21:1348-1358.
19.
NozariASafarPStezoskiSW. Critical time window for intra-arrest cooling with cold saline flush in a dog model of cardiopulmonary resuscitation. Circulation. 2006;113:2690-2696.
20.
BernardSASmithKCameronPRICH Investigators. Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation arrest: a randomized controlled trial. Circulation. 2010;122:737-742.
21.
SagalynEBandRGaleskiDFAbellaBS. Therapeutic hypothermia after cardiac arrest in clinical practice: review and compilation of recent experiences. Crit Care Med. 2009;37(suppl):S223-S226.
22.
HolzerM. Devices for rapid induction of hypothermia. Eur J Anaesthesiol. 2008;25(suppl 42):31-38.
23.
PoldermanKHIngeborgI. Therapeutic hypothermia and controlled normothermia in the intensive care unit: practical considerations, side effects, and cooling methods. Crit Care Med. 2009;37:1101-1120.
24.
MerchantRMAbellaBSPeberdyMA. Therapeutic hypothermia after cardiac arrest: unintentional overcooling is common using ice packs and conventional cooling blankets. Crit Care Med. 2006;34(12 suppl):S490-S494.
25.
DeakinCDNolanJPSoarJ. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation. 2010;81:1305-1352.
26.
KleigalAJanataAWandallerC. Cold infusions alone are effective for induction of therapeutic hypothermia but do not keep patients cool after cardiac arrest. Resuscitation. 2007;73:46-53.
27.
TomteODraegniTMangschauAJacobsenDAuestadBSundeK. A comparison of intravascular and surface colling techniques in comatose cardiac arrest survivors. Crit Care Med. 2011;39:443-449.
28.
RundgrenMRosénIFribergH. Amplitude-integrated EEG predicts outcome after cardiac arrest and induced hypothermia. Intensive Care Med. 2006;32:836-842.
29.
RittenbergerJSanglJWheelerMGuyetteFCallawayC. Association between clinical examination and outcome after cardiac arrest. Resuscitation. 2010;81:1128-1132.
30.
Al-ThenayanESavardMSharpeMNortonLYoungB. Predictors of poor neurologic outcome after induced mild hypothermia following cardiac arrest. Neurology. 2008;71:1535-1537.
31.
RossettiAOUrbanoLADelodderFKaplanPWOddoM. Prognostic value of continuous EEG monitoring during therapeutic hypothermia after cardiac arrest. Crit Care. 2010;14:R173.
32.
LegrielSBruneelFSediriH. Early EEG monitoring for detecting postanoxic status epilepticus during therapeutic hypothermia: a pilot study. Neurocrit Care. 2009;11:338-344.
33.
ChamorroCBarralloJMiguelRSilvaJBalandinB. Anesthesia and analgesia protocol during therapeutic hypothermia after cardiac arrest: a systematic review. Anesth Analg. 2010;110:1328-1335.
34.
KupchikN. Development and implementation of a therapeutic hypothermia protocol. Crit Care Med. 2009;37(7 suppl):S279-S284.
35.
RobinsonLRMicklesenPJTirschwellDLLewHL. Predictive value of somatosensory evoked potentials for awakening from coma. Crit Care Med. 2003;31:960-967.
36.
RothsteinTL. The role of evoked potentials in anoxic-ischemic coma and severe brain trauma. J Clin Neurophysiol. 2000;17:486-489.
37.
LearyMFriedDAGaleskiDF. Neurologic prognostication and bispectral index monitoring after resuscitation from cardiac arrest. Resuscitation. 2010;81:1133-1137.
38.
SederDBFraserGLRobbinsTLibbyLRikerRR. The bispectral index and suppression ratio are very early predictors of neurological outcome during therapeutic hypothermia after cardiac arrest. Intensive Care Med. 2010;36:281-288.
39.
ReisingerJHollingerKLangW. Prediction of neurologic outcome after cardiopulmonary resuscitation by serial determination of serum neuron-specific enolase. Eur Heart J. 2007;28:52-58.
40.
SchaarschmidtHPrangeHWReiberH. Neuron-specific enolase concentrations in blood as a prognostic parameter in cerebrovascular diseases. Stroke. 1994;25:558-565.
41.
MeynaarIAOudemans-van StraatenHMWeteringJ. Serum neuron-specific enolase predicts outcome in post-anoxic coma: a prospective cohort study. Intensive Care Med. 2003;29:189-195.
42.
SesslerCGosnellMGrapMJ. The Richmond Agitation-Sedation Scale. Validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166:1338-1344.
43.
TortoiciMAKockanekPMPoloyacSM. Effects of hypothermia on drug disposition, metabolism, and response: a focus of hypothermia-mediated alterations on the cytochrome P450 enzyme system. Crit Care Med. 2007;35:2196-2204.
44.
ArpinoPGreerD. Pratical pharmacologic aspects of therapeutic hypothermia after cardiac arrest. Pharmacotherapy. 2008;28:102-111.
45.
LeslieKSesslerDIBjorkstenARMoayeriA. Mild hypothermia alters propofol pharmacokinetics and increases the duration of action of atracurium. Anesth Analg. 1995;80:1007-1014.
46.
FrankSMFleisherLAOlsonKF. Multivariate determinants of early postoperative oxygen consumption. Effects of shivering, body temperature and gender. Anesthesiology. 1995;83:241-249.
MuellerSWWinnRMachtMFishDNKiserTHMacLarenR. Neuromuscular blockade resistance during therapeutic hypothermia. Ann Pharmacother. 2011;45:e15.
49.
BadjatiaNStrongilisEGordonE. Metabolic impact of shivering during therapeutic temperature modulation: the Bedside Shivering Assessment Scale. Stroke. 2008;39:3242-3247.
50.
SzumitaPBarolettiSAveryK. Implementation of a hospital-wide protocol for induced hypothermia following successfully resuscitated cardiac arrest. Crit Pathw Cardiol. 2010;9:216-220.
51.
OlgersTJUbelsFL. The ECG in hypothermia: Osborn waves. Neth J Med. 2006;64:350-353.
52.
GrahamCAMcNaughtonGWWyattJP. The electrocardiogram in hypothermia. Wilderness Environ Med. 2001;12:232-235.
53.
BelliardGCatezECharronC. Efficacy of therapeutic hypothermia after out-of-hospital cardiac arrest due to ventricular fibrillation. Resuscitation. 2007;75:252-259.
54.
BernardSBuistM. Induced hypothermia in critical care medicine: a review. Crit Care Med. 2003;31:2041-2051.
55.
MirzoyevSMcLeodCBunchTBellMWhiteR. Hypokalemia during the cooling phase of therapeutic hypothermia and its impact on arrhythmogenesis. Resuscitation. 2010;81:1632-1636.
56.
AbdulAMedouyeA. Is pH-stat or alpha-stat the best technique to follow in patients undergoing deep hypothermic circulatory arrest?Interact Cardiovasc Thorac Surg. 2010;10:271-282.
57.
KollmarRFrietschTGeorgiadisD. Early effects of acid-base management during hypothermia on cerebral infarct volume, edema, and cerebral blood flow in acute focal cerebral ischemia in rats. Anesthesiology. 2002;97:868-874.
58.
BairdTAParsonsMWPhanhT. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcomes. Stroke. 2003;34:2208-2214.
59.
OksanenTSkrifvarsMVarpulaT. Strict versus moderate glucose control after resuscitation from ventricular fibrillation. Intensive Care Med. 2007;33:2093-2100.
60.
ValeriCRFeingoldHCassidyGRagnoGKhuriSAltschuleMD. Hypothermia-induced reversible platelet dysfunction. Ann Surg. 1987;205:175-181.
61.
HerzogEShapiroJAzizEF. Pathway for the management of survivors of out-of hospital cardiac arrest. Crit Pathw Cardiol. 2010;9:49-54.
62.
SchuetzPAffolterBHunzikerS. Serum procalcitonin, C-reactive protein and white blood cell levels following hypothermia after cardiac arrest: a retrospective cohort study. Eur J Clin Invest. 2010;40:376-381.
63.
VaronJAcostaP. Therapeutic hypothermia: past, present and future. Chest. 2008;133:1267-1274.
64.
SmithCNolanJWilliamsM. Enteral feed absorption during therapeutic hypothermia following out-of-hospital cardiac arrest. Crit Care. 2011;15(suppl 1):P377.
