MI with Arctic Sun Induced Hypothermia

Arctic Sun Induced Hypothermia Following Cardiac Arrest

Therapeutic Hypothermia

• AHA Class I recommendation for comatose pts with out-of-hospital cardiac arrest, following ROSC and associated with Vfib (2005)

• Purpose: Decrease brain metabolism for reduced injury and improved outcomes

• Goals:

89.6° - 93.2°F (32° - 34°C), maintained 12-24hrs

Therapeutic Hypothermia

Effects of TH on Metabolism and Feeding Tolerance

Initial Assessment 1/01

• Consult received re: pt NPO on hypothermia protocol

ESTIMATED NUTRITION REQUIREMENTS

Kcal/day: 1462-1657 (18.7-21.2 kcal/kg)

Protein/day: 94 (1.2 gm/kg)

Needs based on: IBW, age, MI, arctic sun protocol (induced hypothermia)

• Decrease in REE ranging from ~75% to 85% of baseline
• Delayed gastric emptying / peristalsis
• Feeding = metabolism = temp

• Very limited research, no clear guidelines for feeding during TH
• Study results (2014): median 72% (~10ml/hr) of feeds tolerated during hypothermia; median 95% of feeds tolerated during warming period
• Sufficient GI function shown at core temperature of 33°C (mid-point of goal 32° - 34°C)

• YNHH Guidelines:
• Cooled or on paralytics = kcal by 15-25%, protein changes
• Shivering or rewarmed = kcal/protein changes

• Benefits of early feeding: maintain GI function, decrease infection risk, prevent bacterial translocation, avoid malnutrition, etc.

Assessment:

• OGT already in place
• Dopamine currently off
• Plans to feed once pt being rewarmed, per team

TYPES OF TH

• Invasive: Peripheral line or vascular catheter
• Non-Invasive: Low room temperature or surface coolants

Follow Up Nutrition Assessment 1/08

Holly Gilligan, Dietetic Intern

Case Study Presentation

July 7, 2015

PHASES OF TH

• Induction: Rapid cooling
• Maintenance: 12-24hrs @ goal temperature
• Re-warming: Active or passive ~14-16hrs
• Target rate of 0.32° - 0.33°F / hr

ESTIMATED NUTRITION REQUIREMENTS

Kcal/day: 1950 (25 kcal/kg)

Protein/day: 94 (1.2 gm/kg)

Needs based on: IBW, MI, arctic sun protocol (induced hypothermia now completed

Assessment:

• New low wt of 77.9kg (admit wt 88kg) 2/2 fluid overload s/p significant diuresis
• Feeds initiated 1/02 ~10am, stopped briefly @ 4pm for GRV 180ml --> goal rate reached on 1/07
• Re-warming started @ 5pm on 1/02 --> completed on 1/03
• Increased stooling 2/2 provision of goal nutrition following constipation
• Tolerating feeds well: 5ml GRV, soft abdomen, +BMs, - emesis

References

PES: Inadequate oral intake --continues

At risk for malnutrition --continues

Intervention:

• Food and/or Nutrient Delivery: Enteral Nutrition (ND-2.1): Transition to Jevity @ 70ml/hr (provides 2016 calories, 93g protein, 1355ml free water)
• Coordination of Nutritional Care: Collaboration with other providers (RC-1.4): Continue to monitor and replete lytes as needed

• Beer R, Fischer M, Dietmann A, Pfausler B, Schmutzhard E. Hypothermia and nutrition: at present more questions than answers? Critical Care. 2012; 16(2). Available at http://ccforum.com/content/16/S2/A28. Accessed August 14, 2013.
• Smith C. Nolan J. Williams M. Enteral feed absorption during therapeutic hypothermia following out-of-hospital cardiac arrest. Clinical Care. 2011; 15910. Available at http://www.ncbi.nlm.nih.govpmc/articles/PMC3067051/?report=classic. Accessed August 14, 2013.
• Erb JL, Hravnak M, Rittenberger J. Therapeutic hypothermia after cardiac arrest. AJN. 2012; 112 (7): 38-44. Accessed at http:/nursingcenter.com/Inc/CEArticle?an=00000446-20120700. Accessed August 14, 2013.
• Williams ML, Nolan JP. Is enteral feeding tolerated during therapeutic hypothermia?. Resuscitation. 2014;85(11):1469-72. Available at http://www.sciencedirect.com/science/article/pii/S0300957214007205. Accessed July 3, 2015.
• Shinada T, Hata N, Yokoyama S, et al. Usefulness of a surface cooling device (Arctic Sun®) for therapeutic hypothermia following cardiac arrest. J Cardiol. 2014;63(1):46-52. Available at http://www.sciencedirect.com/science/article/pii/S0914508713002037. Accessed June 30, 2015.
• Vanlandingham SC, Kurz MC, Wang HE. Thermodynamic aspects of therapeutic hypothermia. Resuscitation. 2015;86:67-73. Available at http://www.sciencedirect.com/science/article/pii/S0300957214007813. 2015.

Patient WT

Baseline Demographics

Age: 55

Admit Date: 12/31/2014

Sex: Male

Dx: MI

Chief Complaint: VF Arrest

Race: African American

Remainder of Hospital Course

Admit Wt: 88kg (194#)

Ht: 70"

Nutrition Diagnosis

Thank You!

IBW: 78kg (172#)

BMI: 27.8

Anoxic Brain Injury Following Cardiac Arrest

PMH/PSH: CAD, PNA, HLD, CHF, Polysubstance abuse (cocaine, MJ, EtOH), LAD stent, AMS, MI ('10, '13)

Inadequate oral intake (NI-2.1) related to intubation/sedation AEB NPO status

Phase 1: Ischemia

Phase 2: Reperfusion

Malnutrition Diagnosis:

At risk for malnutrition based on NPO

Hx of Present Illness: Admit to Backus Hospital 12/28 for SOB, PNA. VF arrest 12/30 --> transfer to ICU --> 2nd, asystolic/PEA arrest 12/31 --> intubated/sedated, transfer to YNHH CCU for cardiac cath and eval for ?implantable defibrillator --> modified chill protocol activated. Poor prognosis

QUESTIONS?

• Multiple failed SBTs 2/2 MS and heavy secretions
• Multiple episodes of NSVT --> amiodarone
• 1/10: L frontal lobe stroke, mental status decline and combativeness requiring continued sedatives --> milrinone
• 1/15: Extubated --> formal swallow eval = dysphagia diet
• Suspected HCAP vs. aspiration PNA -->abx coverage
• 1/20: Re-intubated for tachypnea -->Jevity @ 70ml/hr restarted
• PEG and trach placement d/w family
• Determined as non-candidate for mechanical assist device therapy or heart transplant
• 1/27: self-extubated --> passed 3oz swallow --> regular diet w/ Ensure+ TID
• AKI: Cr peak at 4 --> resolved w/ improvement to 1.8 (baseline)
• 2/06: Biventricular pacemaker placed
• 2/08: Discharged to Harrington Court STR

Medications

Presentation Outline

Labs

Nutrition Intervention

Monitoring and Evaluation

F/U 1/08

Initial Assessment 1/01

• Food and/or Nutrient Delivery: Enteral Nutrition (ND-2.1): Vital AF @ 20ml/hr increasing by 15ml/hr q12h to goal of 65ml/hr via OGT
• Provides at goal 1872kcal, 117g protein, 1265ml free water
• Coordination of Nutritional Care: Collaboration with other providers (RC-1.4)
• Adjust diet order to NPO
• Continue to monitor and replete lytes

• Anthropometric measurements: Weight change (AD-1.1.4)
• Food and Nutrient Administration: Enteral nutrition intake and tolerance (2.1.1.3)
• Biochemical Data: Nutrition related lab values

132

142

3.7

4.4

96

106

20.8

15.8

• Pepcid
• IV Insulin
• Dopamine
• Versed*
• Fentanyl*
• Vecuronium*
• Vanco/Zosyn/Bactrim
• Amiodarone + Milrinone
• Levophed
• Lipitor
• Plavix
• Lasix
• Senna/Colace
• Folic Acid + Thiamine

42

20

Principles of Dietary Management

• Decreased calorie needs for low body temperature
• Semi-elemental formula for tolerance
• K+ and phos requiring multiple repletions

1.8

3.7

134

141

Normal Range - YNHH

Sodium (135-145 mmol/L)

Potassium (3.5-5.0 mmol/L)

Chloride (96-106 mmol/L)

CO2 (22.0-30.0 mmol/L)

BUN (7-20 mg/dL)

Creatinine (0.5-1.2 mg/dL)

Glucose (70-100 mg/dL)

Calcium (8.8-10.2 mg/dL)

Phosphorous (2.5-4.5 mg/dL)

Magnesium (1.7-2.6 mg/dL)

Total Bilirubin (<1.20 mg/dL)

Alk Phos (30-130- U/L)

ALT 0-30 U/L

AST 0-34 U/L

Lactate 0.4-2.2mmol/L

8.7

7.5

3.6

3.0

2.1

1.9

--

2.37

• Anoxic Brain Injury Following Cardiac Arrest
• Therapeutic Hypothermia and various types
• Effects on Metabolism and Feeding

• Case of Patient WT
• Baseline Information
• Nutrition Care Process
• Hospital Course

155

--

49

Complications and Monitoring

84

--

3.3

1.0

Non-Invasive Arctic Sun Protocol

• Core Temperature
• Volume Status
• Cardiac Function
• Central Venous Pressure
• Cardiac Output
• Serum Lactate
• Electrolytes

• Shivering
• Aspiration Pneumonia
• Seizures
• Cardiac Arrhythmias
• Bleeding
• Glucose Abnormalities
• Pulmonary Edema
• Sepsis
• Bacterial Translocation