Research Paper on Effectiveness of Early Therapeutic Hypothermia in Cardiac Arrest Patients

Introduction

Mild therapeutic hypothermia is considered the most effective neuroprotective therapy for cardiac arrest patients. Therapeutic hypothermia is part of the resuscitation care in-patient with ventricular fibrillation (VF) or VT. The aim of the study was to determine the recommended time to initiate therapeutic hypothermia in cardiac arrest patients. There are studies recommending that therapeutic hypothermia should be initiated early (within two hours) while some studies recommend that therapeutic hypothermia should be delayed by six hours (Du, Ge, Ma, Yang, Chen, & Mi, et al, 2017). The outcome of the study should be a Good Neurologic outcome (GNO) or (CPC score of one or 2) while the CPC scores of three, four and or five should be considered a poor neurologic outcome. On the other hand, the phenomenon of interest is therapeutic hypothermia. Most peer-reviewed journals recommend that cardiac arrest patient should be cooled to a temperature between 32 C to 34 C for 12 to 24 hours (Uribarri et al., 2014). Never the less, different targeted temperature management has been proposed by American Heart Association (AHA) Guidelines for cardiopulmonary resuscitation (CPR) as they found that 36 C-TTM and 33 C-TTM is also plausible as compared to the non-targeted temperature management (non-TTM, et al, 2017). Whether following the 320c, 34oc, or 36oc, TTM, the goals of this study is to determine the appropriate time to initiate a therapeutic hypothermia after cardiac arrest (Grossestreuer et al., 2013). The variables in this study would be early therapeutic hypothermic (less than 2 hours) and late therapeutic hypothermia (initiated after 3 hours). The goal was to determine how the delay in initiating TH impact neuralgic outcomes in cardiac arrest patients

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Research Question

When is the most reasonable time to implement therapeutic hypothermia in cardiac arrest patients?

How does time to initiate therapeutic hypothermia relate to the neurologic outcomes

Synthesis of the Evidence

Freiberg, Cronenberg & Nielsen (2015, pp. 2-4) reported that those with good cerebral performances category 1 and category 2 outcomes was between 6.4% to 9.4% after the in-hospital cardiac arrest. On the other hand, Leary, Vanek & Abella (2011, pp, 69-750 reiterated that good temperature management has been one to the most beneficial intervention as targeted temperature management is found to be the gold standard therapy for the comatose patient after the spontaneous circulation returns (Laver, Padkin, Atalla, & Nolan, 2006). However, Yu, & Liu, (2013) argued that "therapeutic hypothermia is the most common therapy for cardiac arrest patients"( pp. e37-e40).

According to Polderman, Nielsen, Graffagnino, & Wayne, (2014), several animal studies support the early initiating of TH among cardiac arrest patients. The same argument as also supported by Kojima et al (2013) who reported that in most of the experimental animals, early initiation of hyperthermia is associated with high survival rates after the return of the spontaneous circulation (ROSC) and intra-arrest cooling before the ROSC. There are several other randomized clinical trials that explore pre-hospital initiation of TH but none of the studies has proven that early TH leads to improved mortality. Only a few studies have demonstrated that neurologic function in the cardiac arrest patient whose cooling measures were started by the emergency medical services personnel before they arrived in the hospitals as compared to those patients whose TH was initiated at the hospitals. On the other hand,

Compare

All the studies supported the argument that initial surface cooling should note started in the first 2 hours. The other studies also indicated therapeutic hyperthermia should be initiated within the first 5 hours making four hours the average time to initiate therapeutic hypothermia. The point of agreement was 4 hours as the average time to for starting the HT. the main argent is that the targeted temperature should be reached within 3.4 hours which is just around the same time that most studies reported. Other findings include the fact that the temperature should be maintained between 32oC and 36oC (class I, level of evidence: B-R)

Contrast

The studies stated that cold saline should be started within the first 5minutes and surface cooling initiated within 25 minutes. This is completely in contrast with what the other studies found to be the appropriate time for initiating TH. For example, after initiating surface cooling in 25 minutes and placing the central line in 30 minutes, other studies reported that initial Lactate should be 9.3, ScVo2 65% and the baseline Temp should be 37.2oC.

What does a study add to the evidence that is unique? Alongi et al (2012) reported that "early therapies hyperthermia could significantly improve the neurologic outcome in cardiac arrest patients" (pp. 124-129). The researcher used Italian Cooling Experiences (ICE) to determine the relationship between the timing of the TH and patient survivals as well as neurologic outcomes. Kojima et al (2013) also found out that the patient in the early intervention group or early initiation group (TH initiated less than 2 Hours) had lower survival rates as compared to those in the late initiation group.

The late intervention or initiation group (Th initiated after 2 hours). The researcher found that while early initiation of the TH is preferred, the TH should not be initiated immediately within the first 2 hours of cardiac arrest. Instead, the TH should be initiated after 3 hours and the temperature should be maintained for at least 24 hours. On the other hand, Walpot, et al (2013) reported that " in the ICU, the mortality rate was high 47.4 percentage for the early initiation groups as compared to the mortality of the late initiation groups (23.8%)" (pp. 150-156). Never the less, Du et al (2017, pp. 130-143)reported that six months mortality was approximately 60.8% as compared to the 40% for early and late initiation groups respectively (p=0.05). the same researchers also reported that cerebral performance category which used as a measure of neurocognitive outcomes at the intensive care unit was 1-2 for the early initiation groups as compared to the late initiating group (1-1) (p=0.57). However, the research outcomes are still subjects to discussion and further experiment because the researcher did not control for the putative confounding factors. No study had similar outcomes as most the studies reported that the patient who had early therapeutic hypothermia and rapid cooling of 163 minutes had poor neurological outcomes

The strength of the study is that that was a systematic analysis and the evidence support early initiation of therapeutic intervention as was supported by most of the studies. However, the limitation of the study is that the study does not provide evidence on the long-term effectiveness and feasibility of the practice at the organizational level.

Conclusion

While TH is associated with reduced hospital mortality for most of Th adult patients that were resuscitated from that non-shock able cardiac arrest, it is important to note that there were risks of bias in most of the studies because the quality of evidence provided was quite low. Both prospective studies and randomized controlled trials have indicated that. It is, therefore, healthy to conclude that early TH among the cardiac arrest patients is associated with higher in-hospital mortality rates as compared to the late TH. ROSC should be 30 minutes and the TH should start at least 3 hours from the ROSC, the targeted MAP should be higher than or equal to 65mmHg.

Implication for Practice

Achieving the selected targeted temperature may be the goal for TH. However, it is important for nurses to try to control the body temperature of the cardiac arrest patient for at least 30 hours after the cardiac arrests. The brain's level of temperature sensitivity can last as long as the brain dysfunction (coma) continues. Therefore nurse should change to early TH (3 hours after cardiac arrest) and maintain the temperature for a minimum of 24 hours because 24 hours is the recommended duration of the TTM

Plan of Action

Changes are inevitable but the research outcomes present better patient outcomes. Change may also attract resistance, which calls for change management strategies. It is therefore important for the hospital management to take the burses through a change management process such as the processes proposed by Kurt Lewin. Kurt Lewin proposed that change should start with Unfreezing- Change - Refreeze. The unfreezing phase involves teaching the nurse why there have been new protocols and the benefits of such protocol for TH for the nurses and the patient. The change phase s where the nurses would start adopting the new optimal timing for initiating TH in cardiac arrest patient. The refreeze stage is where the nurses would be motivated to incentivize to continually initiate TH within 6 hours after cardiac arrest. Finally, the reinforcing such practices should be done through continuous nurses education, monitoring and evaluation.

Recommendation for Future Research

Future research should conduct subgroups analysis to determine and compare the effects of early TH and later TH on both the shockingly cardiac arrest patient and non-cardiac arrest patients

References

Alongi S, Raffaeli M, Guatteri L, Panigada M, Colombo R, Ronzoni G, Beck E, Rossi S, Balicco B, Dossena R, Pontecorvo C, Armani S, Artini D, Campanile V, Verginella F, Pellis T, Todesco L, Bianchin A, Lodi G, Perzolla D, Cubattoli L, Ciani A, Benanti C, Viaggi B, Polli F. (2012). Early- versus late-initiation of therapeutic hypothermia after cardiac arrest: Preliminary observations from the experience of 17 Italian intensive care units. Resuscitation, 83(7), 823-828. doi: 10.1016/j.resuscitation.2011.12.002

Du, L., Ge, B., Ma, Q., Yang, J., Chen, F., & Mi, Y. et al. (2017). Changes in cardiac arrest patients' temperature management after the publication of 2015 AHA guidelines for resuscitation in China...