Running head: THERAPEUTIC HYPOTHERMIA

Therapeutic Hypothermia: An Evidence Based Approach Andrea Mygrants Ferris State University

THERAPEUTIC HYPOTHERMIA Abstract An important aspect of professional nursing practice is the use of evidence-based practice. As new research becomes available, nurses should expect to critically evaluate this research and decide if the evidence suggests practice change. This paper used the process of evidence based practice to look at the question: Does therapeutic

hypothermia increase survivability and improve brain function compared to no therapeutic hypothermia in adult post cardiac arrest patients? The research was then reviewed, which found that therapeutic hypothermia does in fact improve survivability and improve brain function. The findings of this review are that emergency and critical care nurses involved in caring for post cardiac arrest patients should educate themselves on this therapy and advocate for its use.

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Therapeutic Hypothermia: An Evidence Based Approach The purpose of this paper is to examine a nursing based question in the PICO format. This format helps to define the characteristics of a question and includes the following elements. P stands for population, what people are affected by this problem? I stands for intervention, what intervention or variable is being studied? C stands for comparison or control, what is the intervention being compared to? O stands for outcome, what are the results or expected results of the intervention? The PICO question that I have chosen to examine is: Does therapeutic

hypothermia increase survivability and improve brain function compared to no therapeutic hypothermia in adult post cardiac arrest patients? To examine the question a review of current research was done from the databases available at Ferris State University.
PICO Question Cardiac arrest occurs when the heart stops pumping blood. Cardiac arrest can be caused by many conditions, but the treatment is the same with early CPR, defibrillation, and medications. For those who are lucky enough to survive a cardiac arrest, there is also a great risk of hypoxic brain injury. This is where therapeutic hypothermia can be useful. The theory is that by reducing the body temperature of a post cardiac arrest patient to 33 degrees Celsius for 24 hours after a cardiac arrest event, hypoxic brain injury can be limited, and patient outcomes improved. (Nolan, Morley, Vanden Hoek & Hickey, 2003) . Collaboration with physician and nursing staff in both the emergency room and the intensive care unit is key to initiate a therapeutic hypothermia protocol. Cardiac arrest patients that come in through emergency are resuscitated and stabilized.

THERAPEUTIC HYPOTHERMIA Emergency Room physicians and nurses then determine if the patient meets inclusion criteria for therapeutic hypothermia and begin the rapid cooling process. Important patient information is then passed to intensive care doctors and nurses where they continue the cooling process and monitor the patient. Intensive care nurses also initiate the gradual rewarming process and monitor for complications. Communication between nurses and physicians is key to positive patient outcomes. Research Findings

In reviewing research for therapeutic hypothermia, I began with a research article in the New England Journal of Medicine, Mild Therapeutic Hypothermia to Improve the Neurological Outcome After Cardiac Arrest. Even though this research article is not nursing based research, it is cited in many following research articles as a landmark study. This study was a randomized trial with patients being assigned to treatment or control groups if they met inclusion criteria. This study found a 55% favorable neurologic outcome for the treatment group vs. 39% in the control group. They also found a 6-month mortality rate of 41% for the treatment group vs. 55% for the control group. (Hypothermia after Cardiac Arrest Study Group, 2002) This article should be given strong consideration when reviewing the question of whether or not to implement a therapeutic hypothermia protocol within the emergency room or ICU setting for post cardiac arrest patients. This article is found in a well respected, peer reviewed journal with an impact factor of 51.658 in 2012. The study itself is quantitative research with a randomized double blind design. The second article that I reviewed was from the journal, Dimensions of Critical Care Nursing. This article, How Effective Is Code Freeze in PostCardiac Arrest

THERAPEUTIC HYPOTHERMIA Patients?, by Jenny Jolley DNP-C, MSN, FNP-BC, and Roy Ann Sherrod, DSN, RN, CNS, CNL, is a retrospective review that looks at the effectiveness of therapeutic hypothermia. Their findings were similar to the findings of the Hypothermia After Cardiac Arrest Study Group previously discussed. While this study looked only at survival rates and not neurological functioning, they still found positive results and recommended therapeutic hypothermia as an effective intervention to improve patient outcomes in cardiac arrest patients. (Jolley & Sherrod, 2013) While this article gave convincing evidence, it should be noted that it does not have a high level of evidence. It is quantitative research, but it is not randomized or controlled. It is also a retrospective study which means that variables such as researcher bias is much more difficult to control for. Upon further research, the journal that this article is published in is not peer reviewed, and I could not locate an impact factor. While this article should not be used solely to make practice decisions, it did bring up an important point that the identification of potential patients and the implementation of therapeutic hypothermia protocols can be nurse driven. Many of the other articles that I found were reviews or commentary, and did not give any original quantitative or qualitative research data. Therefore, I finished my research by looking to the Cochrane Review database and was able to find a metaanalysis about therapeutic hypothermia. The inclusion criteria for analysis was, randomized studies on adult cardiac arrest patients treated with therapeutic hypothermia. (Arrich, Holzer, Havel, Mullner & Herkner, 2012) Overall the review ended up including 3 randomized trials with a total of 383 patients. The results of the

review showed that, With conventional cooling methods like cooling blankets or cooling

THERAPEUTIC HYPOTHERMIA helmets, patients were 55% more likely to leave the hospital without major brain damage. They also showed that therapeutic hypothermia had no increase in

complications in comparison to standard supportive care. (Arrich, Holzer, Havel, Mullner & Herkner, 2012) The Cochrane Library is an online repository for all of the Cochrane reviews, and is a widely respected organization. The Cochrane Library also uses a peer review process prior to publishing review findings and has an impact factor of 5.785. This review is also a meta-analysis of quantitative controlled studies, which makes this the highest level of evidence. Many healthcare organizations rely on Cochrane to guide them in evidence based practice. I believe their findings to support the use of therapeutic hypothermia is a strong recommendation for hospitals to implement this therapy. Recommendations to Improve Quality and Safety With the research showing clearly that initiating therapeutic hypothermia in post cardiac arrest patients has improved patient outcomes with low risk of complication, the next step is to implement this into hospital policy. Fortunately this therapy is also low cost with the hospital only needing to purchase a few thermal control blankets, and refrigerators to store iced IV solution. After equipment is purchased, the hospital would then have to create a treatment protocol and train staff on the new procedures. Important to treatment will also be in the identification of patients who are eligible to receive the therapy. There are some contraindications to post cardiac arrest hypothermia such as end stage disease, active bleeding, coagulopathy, prolonged resuscitation of greater than 60 minutes, and pregnancy. (Kupchik, 2009) Patients who regain consciousness following resuscitation are also excluded. Once a patient is

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identified as a candidate for therapy, it will be a nursing driven process to implement and manage the therapy. Overall therapeutic hypothermia can and should be a nurse driven protocol, and will give nurses an opportunity to display professional practice through interdisciplinary communication and collaboration. Conclusion In conclusion, therapeutic hypothermia for post cardiac arrest patients is an important intervention to increase survivability and decrease neurologic damage. Nurses should base their care on evidence-based practice, which in this case is supported by the available research. Nurses who are involved with therapeutic hypothermia should also recognize that this is a newer therapy and research on the optimal delivery is still in progress. A periodic review of literature should be done to ensure that protocols and inclusion criteria are based on current evidence.

THERAPEUTIC HYPOTHERMIA References Arrich, J., Holzer, M., Havel, C., Mullner, M., & Herkner, H. (2012). Hypothermia for

neuroprotection in adults after cardiopulmonary resuscitation (review). Cochrane Database of Systematic Reviews, (9), doi: 10.1002/14651858.CD004128.pub3. Hypothermia after Cardiac Arrest Study Group. (2002). Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. The New England Journal of Medicine, 346(8), 549-556. Jolley, J., & Sherrod, R. (2013). How effective is code freeze in postcardiac arrest patients?. Dimensions of Critical Care Nursing, 32(1), 54-60. doi: 10.1097/DCC.0b013e3182768400 Kupchik, N. (2009). Development and implementation of a therapeutic hypothermia protocol. Critical Care Medicine, 37(7), S279-S284. doi: 10.1097/CCM.0b013e3181aa61c5 Nolan, J., Morley, P., Vanden Hoek, T., & Hickey, R. (2003). Therapeutic hypothermia after cardiac arrest:an advisory statement by the advanced life support task force of the international liaison committee on resuscitation. Circulation, 108, 118-121. doi: 10.1161/ 01.CIR.0000079019.02601.90