9/1/2014

Hospital of the University of Pennsylvania

Post-Cardiac Arrest Care / Targeted Temperature Management
Pathway Order Set
CALL THE RESUSCITATION TEAM: 267-253-9035
Admission
ICU admission order set
o Post-Cardiac Arrest Care/
Targeted Temperature Management
Code Status:
Full Code
DNAR-A (for patients post-cardiac arrest)
Targeted
Targeted Temperature
Temperature Management
Management
Note: Based upon new evidence in a large European clinical trial, consider 360C
target for a patient whom otherwise would be excluded from the 330C TTM protocol.
These patients can be treated to a TTM target of 360C for 24 hours, followed by
standard rewarming.
Key differences in the 360C protocol are:
The patient will not receive 2 liters of cold (40C) saline, unless the initial
temperature is greater than 370C.
The surface cooling device is set to a target of 360C with an acceptable patient
response of 350-370C.
The patient will rewarm at a controlled rate of 0.330C/hour.
Paralytics will be discontinued when patient reaches 36.5-370C.
Note: Consider Head CT prior to initiating Targeted Temperature Management (TTM)
as deemed medically necessary. For those patients requiring a Head CT, Targeted
Temperature Management may be initiated prior to receiving the Head CT.
Note: Determination of Neurologic Prognosis is unreliable before at least 72 hours
after ROSC. Do not neuroprognosticate until 72 hours post rewarming.

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Note: Please document in the Comment section of Sunrise: time/date TTM initiated,
target temperature reached, rewarming initiated, normothermia reached. If TTM is
initiated in the Emergency Department please document time/date TH was initiated
in the ED during RN report.
Exclusion/Contraindications:
Note: These are exclusion criteria only. If the patient is not excluded by these
criteria, TTM should be performed on a case by case basis, unless contraindicated.
> 12hrs since Return of Spontaneous Circulation (ROSC) (Data support cooling
patients as soon as possible post-cardiac arrest)
Glasgow Motor score >5
Minimal pre-morbid cognitive status
Other reason for comaintracranial pathology (i.e. intracranial hemorrhage,
ischemic stroke), subarachnoid hemorrhage (SAH), sedation
Sepsis as etiology for arrest
DNAR B & C/DNAI status (for TTM only)
Uncontrollable bleeding
Significant trauma, especially intra-abdominal such as splenic or liver laceration
(due to increased risk of bleeding)
Equipment List
Arterial line kits (both radial and femoral)
PreSEP central venous catheter
Two one liter bags of 0.9% NaCl at 4 degrees Celsius
Gaymar III external cooling system
o One Gaymar torso and two thigh cooling pads
Temperature probe foley catheter with appropriate adapter for cooling device or
alternative temperature monitoring device
Neuromuscular blockade equipment
o Peripheral Nerve Stimulator (See TTM specific TOF policy)
o Consider use of BIS monitor and sensor for monitoring sedation
Fluid warmer if needed

Sedation/Anesthetic/Neuromuscular Blocker (NMB)

Should administer one or more of the following:
Fentanyl Injection 50 mcg IV every hour as needed for pain. If using BIS
monitor, titrate to 40-60.
Fentanyl IV infusion NSS (8000mcg/250mL). Administer per ICU protocol
(Critical Care Nursing Policy CCC-05-05). If using BIS monitor, titrate to 40-60.

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Propofol IV infusion (1000mg/100ml). If using BIS monitor, titrate meds to keep

BIS 40-60. Administer per ICU protocol. Max rate of 80 mcg/kg/min. Note:
Propofol interferes with measurement of aPTTs. Please consider this when
ordering propofol on patients already on heparin and use Factor Xa levels to
monitor anticoagulation
Lorazepam IV infusion (2mg/ml). Administer per ICU protocol. If using BIS
monitor, titrate to 40-60.
Lorazepam Injection 1 mg IV every 2 hours as needed for agitation. If using BIS
monitor, titrate to 40-60.
Pancuronium IV infusion NSS (100mg/250 ml) Administer per ICU protocol
(Critical Care Nursing Policy BCC-03-26; Use TTM TOF protocol for titration).
Initiate pancuronium before initiating cooling. Dosing recommendations: 0.1
mg/kg loading dose followed by a continuous infusion of 0.33-2 mcg/kg/minute.
*Do not use in patients with renal and/or hepatic insufficiency.
Cisatracurium IV infusion (200mg/250ml). Administer per ICU protocol (Critical
Care Nursing Policy BCC-03-26; Use TTM TOF protocol for titration). Initiate
cisatracurium before initiating cooling. Dosing recommendation: 0.1-0.2 mg/kg
loading dose followed by a continuous infusion of 0.5-10 mcg/kg/min. Can be
used in patients with renal insufficiency defined as a creatinine clearance <10
ml/min and/or hepatic insufficiency defined as total bilirubin >3mg/dl
associated with liver disease or dysfunction.
Ophthalmic Lubricant Ointment 3.5gm Dose 1 application both eyes every 2
hours for: Eye Lubrication Prophylaxis.

Nursing
Cooling
o Infuse 2 liters 0.9% NaCl at 4 C over 30 minutes if no evidence of
Pulmonary Edema; See Critical Care Nursing Policy: Post cardiac arrest
therapeutic hypothermia (TTM) policy BCC-04-05
o Insert intra-vesicular (bladder) catheter with temperature probe - Bard
Temperature Sensing Foley 400 Series (product #90911616 no
minimum urine output required for use). If bladder temperature is not
available or inaccurate consider alternative site (i.e. esophageal probe).
NOTE: If bladder pressure is being measured it is recommended that an
esophageal probe be used for temperature monitoring.
o Goal temperature of 32-34 C as soon as possible (within 4 hours)
If using BLUE-faced Gaymar III set to Automatic mode, set point 33
Rapid mode, for 24 hours from time target temperature reached.
If using GRAY-faced Gaymar III set to Automatic mode, Rapid cooling, set
point 34C. Once the patient reaches 34C set to Gradual mode at 33C

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Note: Please document in the Comment section of Sunrise: time/date TTM

initiated, target temperature reached. If TTM is initiated in the Emergency
Department please document time/date TH was initiated in the ED during RN
report.
Re-warming
o Initiate 24 hrs after target temperature was reached per RN policy
o Caution: check blood sugar prior to rewarming. Monitor for hypoglycemia
during the rewarming phase.
o Rewarm to 37 C
o If using BLUE-faced Gaymar III with Automatic re-warming algorithm,
set to Automatic mode, set point 37 Moderate mode. The moderate
mode will increase the set point automatically 0.33 every hour (~12
hours).
o If using GRAY-faced Gaymar III with Manual re-warming, set to Manual
mode and manually increase the blanket temperature 0.33C every 1
hour until the patient temperature reaches 36C.
o Hold all K+ containing fluids if K+ > 3.5 immediately before and during
re-warming
o Change IV fluids to 0.9% NaCl, titrate to CVP >8 mmHg, maintaining a
MAP > 80 mmHg, and no evidence of shock (by exam, urine output,
lactate, and ScvO2)
o Stop NMB infusion after core temperature reaches 36 C
o Meperidine 12.5-25 mg q4-6 hrs IVP (but not to exceed 100 mg/day) can
be used to treat shivering once NMBs have been stopped (if renal failure
or oliguria is not present and patient not taking an MAO inhibitor or SSRI).
Warning: Should NOT be given at all in late term pregnancy or for
prolonged use at any time during pregnancy. Caution: there is a
potential interaction between Meperidine and Buspirone although no
known cases of an interaction have been documented in the literature.
o Maintain active normothermia for 48 hours: keep cooling wraps on the
patient for 48 hours after rewarming and administer acetaminophen
around the clock for the same 48 hour time period. Monitor skin
breakdown closely during this time.
Note: Acetaminophen should not be administered in patients with fulminant
hepatic failure. Use caution in patients with chronic liver disease or acute liver
injury. Consider decreased dosing in this patient population, not to exceed 2
grams daily.
Note: Please document in the Comment section of Sunrise: time/date rewarming
initiated and normothermia reached.
Post-Cardiac Arrest Early Goal Directed Therapy

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Post-Cardiac Arrest Early Goal Directed Therapy

IV Fluids
Note: If Acute Coronary Syndrome suspected, first transfuse blood to Hgb 10.
Patient with MAP < 80 mmHg: 0.9% NaCl IV x 2 liters titrate to CVP >8
mmHg, until MAP > 80 mmHg and ScvO2 greater than or equal to 65%, unless
signs of pulmonary edema
If K less than 5, switch to Lactated Ringers (provided no contraindications, i.e.
advanced liver disease, increased potassium) after 2 liters 0.9% NaCl infused
(This includes the 2 L cold saline for initiation of TTM) - titrate to CVP >8
mmHg, until MAP > 80 mmHg and ScvO2 greater than or equal to 65% unless
signs of pulmonary edema
If ScvO2 < 65% and/or any signs of shock, with no pulmonary edema:
continue with 0.9% NaCl boluses up to a total of 2 liters and titrate to CVP >8
mmHg and Scv02 greater than or equal to 65%.
Note: If showing signs of pulmonary edema consider stopping fluid
resuscitation. If no signs of pulmonary edema and additional resuscitation
needed, continue with Lactated Ringers if K+ less than 5.0 mEq/l
Note: Consider monitoring Intra-abdominal pressure if > 5 liters of IVF given in
24
hours
Vasoactive Agents
-If hemodynamically unstable, STAT echocardiogram to determine Ejection Fraction
Hypotension, Ejection Fraction greater than or equal to 50%
o Norepinephrine infusion: Begin at 2-4 mcg/min, titrate to maintain MAP
>70-80 mmHg
Hypotension, Ejection Fraction less than 50%
o Norepinephrine infusion: Begin at 2-4 mcg/min, titrate to maintain MAP
>70-80 mmHg; (max infusion rate 60 mcg/min)
o Begin Dobutamine infusion at 2.5 mcg/kg/min to maintain a MAP of >7080 mmHg and/or ScvO2 >65%; (max infusion rate 20 mcg/kg/min).
o Begin Epinephrine infusion at 2 mcg/min to maintain ScvO2>65% (max
infusion rate of 20 mcg/min).
Note: If the above therapies fail and hypotension severe, consider Intra-aortic
balloon pump
ScvO2 (by co-oximetry) < 65% with CVP 15-20 mm Hg or CHF

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o If MAP is < 60 mmHg, begin norepinephrine infusion: Begin at 2-4

mcg/min, titrate to maintain MAP >70-80 mmHg.
o Begin Dobutamine infusion at 2.5 mcg/kg/min to maintain ScvO2 >65%
(max infusion rate 20 mcg/kg/min)
o Consider transfusing Packed Red Blood Cells to keep Hemoglobin greater
than or equal to 10 g/dL once CHF clears
Hypertension
Begin Nitroglycerin infusion at 10 mcg/min (max 200 mcg/min) for MAP
>100 mmHg - titrate to MAP goal
Hypertension with tachycardia or acute ischemia/MI without LV
dysfunction: Initiate Esmolol and titrate to HR <100. Initiate 50
mcg/kg/min, increase by 50 mcg/kg/min increments to max rate of 300
mcg/kg/min
Initial Laboratories
Beta HCG on all women of childbearing age

ABG with Ionized Calcium and Magnesium

CBC/ platelets / PT / PTT/INR, Fibrinogen

Electrolyte panel 7, plus iCa / Mg / Phos , Cl-, Glucose

Amylase, Lipase

Liver Function Panel

Lactate, CPK-MB, CK, Troponin

Cortisol level (If Indicated)

Pan-culture - Blood Culture, Urine Culture, Urinalysis, Sputum Culture (if

appropriate)

Toxicology screen if appropriate

Co-oximetry on Central Venous blood
Serial Laboratories:
Note: For ABG and Co-oximetry Panel: Do not temperature correct.

ABG q 6 hrs and prn

Co-ox (Central Venous) q 1-2 hrs for first 6hrs then q 6 hrs - until re-warming process
complete if continuous Sv02 catheter not used

Glucose, K+, and lactate q 6 hrs - until re-warming process complete

Repeat CPK-MB, CK, Troponin q 6 hrs - until re-warming process complete

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CBC/ PT / PTT/INR, fibrinogen, P7 / Ca / Mg / Phos q 6 hrs

Monitoring:
Continuous EEG monitoring - page EEG fellow at 215-404-6771
before midnight if possible; EEG must be hooked up within 6-12 hours of TH
initiation. EEG should not be discontinued until the patient is re-warmed and
paralytics are discontinued.
For issues or concerns, if you cannot get a hold of the EEG fellow, please
page the Neurology resident on-call.
See EEG quick sheet in the appendices. This is for educational purposes
only.

Core Temperature - continuous

CVP q 1hour with Vital Signs during active cooling/re-warming; q 4 hours

during maintenance
Check patient skin (especially under the wraps) q 4 hours
When clinically appropriate, consider SSEP ordered on day 3 (72 hours postROSC) - Place order for Somatosensory Evoked Potential in Sunrise
with a note that states post-cardiac arrest or for questions call
the lab at 215-662-2661.
Nutrition NPO
Insert OG tube, keep Head of Bed (HOB) greater than 30 degrees at all times
and follow Gastric Residuals per ICU protocol
X-ray to confirm placement of OGT

Electrolytes
Potassium Chloride (40 mEq in 100ml)
40 mEq in normal saline 100 ml IV piggyback Every 6 hours PRN
Hypokalemia less than 3.4.
Note: For patients with renal insufficiency, call MD for adjusted dosing.
-For potassium >3.5 mmol/L while rewarming Do Not Replete
-For potassium 3.0-3.5 mmol/L: 40 meq/100 mLs SWFI (infuse over 2 hrs)
-For potassium 2.5-3.0 mmol/L: 60 meq/150 mls NaCl 0.9% (infuse
over 3hrs)

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-For potassium <2.5 mmol/L: 80 meq/L Infuse each 40meQ/100 mLs

SWFI over 2 hours
Magnesium Sulfate Injection
1 gm Intravenous in D5W 100 ml IV piggyback Every 6 hours PRN
Hypomagnesemia (less than 1.8 mg/dL)
Calcium Chloride Injection
1 gm in D5W 100 ml Intravenous piggyback Every 4 hours
As needed for ionized calcium levels less than 0.9. If repleting, check
ionized calcium levels every 4 hours
Sodium Phosphorus Infusion
10 mMol(s) in sodium chloride 0.9% - 500ml IV piggyback every 6 hours
PRN Hypophosphatemia less than 2.5 mg/dL.
-For phosphate levels > 2.5 mg/dL No Replacement Needed
-For phosphate levels 2.0-2.5 mg/dl Infuse Sodium Phosphate 10
mmol/100 mLs sodium chloride and infuse over 4 hours
-For phosphate levels <2.0 mg/dl Infuse Sodium Phosphate 20
mmol/250 mLs sodium chloride and infuse over 6 hours
Blood Products
Education: if significant bleeding ensues while hypothermic, coagulopathy
should be corrected aggressively. In the absence of overt bleeding, the decision
to correct coagulopathy is up to clinical judgment after weighing the risks and
benefits of blood product replacement in each individual case.
Note: PRBC: Transfuse 1-2 PRBC to Hgb > or = 10 for patients with ACS or
shock with ScvO2 less than 65, after correction of low CVP and MAP.
Platelet count < 20K or <50K with active bleeding: Platelets 6 units
With active bleeding - INR > 1.5: FFP _____2 units ____4 units
PRBC for ACS or any evidence of shock despite CVP>8-12 mm: ____1 unit
____ 2 units
PRBC for Hgb < 7: _____1 unit ____2 units
PRBC for Hgb < 10 if active bleeding: _____1 unit ______2 units PRBC
Pre-medications for PRBC & Platelets (unless hypothermic)
Choose appropriate Acetaminophen and Diphenhydramine Dose and
Route:
Acetaminophen Liquid 160 mg/5ml - Give 650mg Orogastric Tube Once
Total Per Dose 650 mg

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Acetaminophen Supp 650 mg Total Per Dose 650 mg

Diphenhydramine 25 mg IV Once Total Per Dose 25 mg

Diphenhydramine Liquid 25mg/10ml - Give 25 mg Orogastric Tube Once
Total Per Dose 25 mg
Insulin Therapy
Initiate per HUP/ICU Insulin Infusion Protocol for two consecutive blood
glucoses > 150 mg/dL
Caution: check blood sugar prior to rewarming. Monitor for hypoglycemia
during the rewarming phase
Respiratory
If ALI/ARDS use Low Stretch protocol
Arterial pH Goal: 7.30 7.45.
FiO2 Goal is < .70. Wean FiO2 and maintain for SaO2>92% or <95% or
PaO2> 85 mmHg and <110mmHg
Ventilator Modes Low stretch protocol:
Use patient height to calculate Tidal Volume (TV) per Predicted Body Weight
(PBW) and gradually reduce TV to 6 ml/Kg/PBW; monitor and maintain plateau
pressure 30 cm H20
Radiology
CXR now
Repeat CXR in AM and after 72 hours
Head CT to rule out intracranial hemorrhage, or other causes of coma, if
clinically appropriate
Cardiology
Call Cardiology for:
o hemodynamic instability, indeterminate ECG or suspected NonSTEMI, or arrhythmia (use Cardiology Consult pager)
o Acute STEMI (Use STEMI Activation Cell Phone)
ECG STAT
ECG q 8 hours x 2
Echo
-Consider early Echo if requested by Cardiology Consult, or in the case of
any of the following:
-Ongoing hypotension with possible cardiac etiology
-Ongoing arrhythmias
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-Indeterminate ECG
Or, obtain routine Echocardiogram within first 24-48 hours of protocol
Repeat echocardiogram 24-48 hours
Aspirin: _300___mg per rectum OR _325__mg OG STAT Once for Acute
Coronary Syndrome, unless contraindicated (i.e. allergy or active bleed)
DVT Prophylaxis
Heparin 5000 units SubQ q8 hrs
Intermittent Compression Stockings
GI Prophylaxis
ranitidine oral liquid 15 mg/ml solution 150 mg orogastric tube
ranitidine IVPB, 50 mg IV piggyback
Shivering
Meperidine 12.5-25 mg q4-6 hrs IVP (not to exceed 100 mg) can be used to
treat shivering once NMBs have been stopped (if renal failure or oliguria isnt
present and patient not taking an MAO inhibitor, or SSRI).
Warning: Should NOT be given at all in late term pregnancy or for
prolonged use
at any time during pregnancy. Caution: there is a potential interaction
between Meperidine and Buspirone although no known cases of an
interaction have been documented in the literature.
Consults
Cardiology consult for:
- hemodynamic instability, indeterminate ECG or suspected Non-STEMI, or
arrhythmia (use Cardiology Consult pager)
- Acute STEMI (Use STEMI Activation Cell Phone)
Neurology for all post cardiac arrest patients
Nutrition Support Services on day 3
Maternal-Fetal Medicine if + HCG (while initiating hypothermia)
Resuscitation consult team 267.253.9035
Utilize Nursing Policy BCC-03-26 Neuromuscular Blockade (NMB) Therapy for guidance on use of
peripheral nerve stimulator and train-of-four (TOF) monitoring. Use algorithm below for NMB dose
titration in Targeted Temperature Management.

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Therapeutic goal: Prevention of shivering. Patients may initiate breaths on ventilator without shivering occurring. NOTE: Lower d

Consider increased doses of NMB to paralyze diaphragm when there is need to decrease oxygen consumption, decrease plat

Determine baseline TOF Administer loading dose

Begin infusion

Recheck Train of Four in 1 Hour

TOF 0/4
Decrease dose of infusion by 10%
Recheck in 1hr

TOF 0/4
Decrease dose of infusion by 10%
Recheck in 1hr*

TOF 1-2/4
Therapeutic goal met:
No change

TOF 1-2/4
Therapeutic goal met:
No change

TOF 1-4/4 and shivering Therapeutic goal NOT met:

Administer ordered bolus dose
infusion by 25%
Recheck in 1hr

TOF 3-4/4 or 1-4/4 an

Therapeutic goal
Administer ordere
infusion
Reche

TOF 3-4/4 or 1-4/4 a

Therapeutic goa
Administer ordere
infusio
Rech

*Continue to decrease dose by 10% until evidence of shivering is present or minimum

recommended dose in dosing range is reached. Do not discontinue drug.

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