Targeted Temperature

Management After Low Flow

Circulatory Failure; What
Nurse Should Do?

Ns. Ryan Budiyanto

Presented in The 2nd

IACVC National Webinar
2022
 INTRODUCTION
• The post cardiac arrest syndrome is a subsequent morbidity and
Leading to consecutive deadly event after Cardiac Arrest.
• Post Cardiac Arrest Brain Injury (PCABI) is the main cause death
& cause of long-term disability in those who survive the acute
phase
• Targeted temperature management (TTM), so-called
therapeutic hypothermia, improves survival and neurological
outcomes in comatose survivors of cardiac arrest
• TTM on adult CA in the field according to feasibility, facility and
well-trained provider Pretty much Challenging.
 BACKGROUND
Incidence of Adult Cardiac Arrest in NCCHK
When do people die after cardiac arrest during mid 2018-Early 2019 (n=155)
In Percentile
Arrest 90
CPR 80
81,1 77,9
70
% Surviving

60 52,3
IHCA 47,7
ROSC 50
17 % 40
30 18,9 22,1

Hospital 20
10
Discharge
0
ARREST ROSC DEAD
Time
Mid-2018 Early-2019

Girotra, S., Chan, P. S., & Bradley, S. M. (2015).. Heart, 101(24), 1943–1949.
 POST CARDIAC ARREST SYNDROME
MORE
EFFECTIVE Systemic Persistent
Reperfusion Precipita<ng
Injury pathology

TTM Post Cardiac

Arrest
Syndrome

Post CA Post Anoxic

Myocardial Brain Injury
Nolan jp et al, Resuscitation, 2008. Injury
 POST CARDIAC ARREST CARE
American European

A
B
C

ABC & Temperature

management
Continuous Management & Emergent Activities
Multi-center RCT of adult 1850 OHCA. Rigorous, well performed
investigation.
TTM2 trial Translating
• Target temperatures maintained for 28 hours,
12-hour period of rewarming and sedation in • Targeted temperature
the hypothermia group, for a total intervention management involving
period of 40 hours.
• Normo group : IV device (31%), surface (69%)
pharmacotherapy, device
• Normo Group more likely to have
cooling, and timely neurologic
acetaminophen (6000 mg vs. 4875 mg). prognostication.
• Hypo Group ( 70% SCS, IVTM 30%)
• Hypothermia group NMB (66 vs 45%) 10-15%
temperature 37.7’C in 40-72 after
randomization
• Avoid Premature withdrawal Life sustaining
therapy (WLST)
Reality of Scientific Progress

TTM works for

Everyone
TTM works for
Some

TTM works for

no One
 PCAC

36’C

33’C

33’C

PCAC 2 TTM 36’C = better outcome

PCAC 3-4 with TTM 33’C higher survival & less neurological devastation
What does it takes to re-define standard of care
Can neutral studies debunk positive studies?

Posi<ve Studies
Neutral Studies
Bernard
TTM 2
Hyper-ion
TTM
HACA

32-34˚C Not 32-34˚C

Beyond one fits for all PCAS

 The Era of High Quality TTM

Low quality High quality

Taccone, Cri$cal Care, 24(1), 1–7 2020

 TTM Adverse effects

• Possible causes electrolytes

imbalance, fluid status,
temperature affect cardiac
myocytes.
Perman, S. M., (2014).. Chest, 145(2), 386–393. https://doi.org/10.1378/chest.12-302
Dankiewicz, J. et al. Nejm. 2021
 Equipment
Head wrap Blanket
Surface cooling Probe temperature
 TTM’s Method in IACVC
The core temperature measured in
Body Surface Cooling nasopharynx 34°C at least for 24 H
Fully sedated Head Wrapped
 Procedure Targeted Temperature Management

32-36°C

24-48 Hour

0,25-0,5°C/ Hour

6 Hour 12 Hour
1.Fukuda, T. (2016).. Journal of Intensive Care. https://doi.org/10.1186/s40560-016-0139-2
2. Nolan, J. P. (2015).. Resuscitation, 95, 202–222. https://doi.org/10.1016/j.resuscitation.2015.07.018
Prognostication
 NURSING ROLE in TTM Patient
• Assessment of the exclusion criteria
• Reduce delayed time to attempt TTM
• Downtime max 60 minutes after ROSC
PRE-INDUCTION • Optimizing coordination between ED and CVICU Through Team
Leader/MPP
• Patient/’s Family education

• Set the goal temperature at 32-36ºC on cooling device

T INDUCTION PHASE • Obtain a core temperature measurement tools inside of patient’s
nasopharynx, use double measurement for comparison (core and surface)
T
• Ensure the waterflow from the device is not blocked
M
• Monitor for seizure/ shivering using BSAS
• Control constant core temperature at 34’C
P
MAINTENANCE • Monitor Sedation status using SAS
H • Optimizing hemodynamic profile
A • Optimizing nutritional, metabolic component

S
• Rewarming should be started after the time targeted of maintenance
E phase has achieved
REWARMING • Temperature should rise at range 0,25-0,5 “Celsius per hour max 37,5 º C
• Prevent rebound hyperthermia at least 72 Hour after ROSC
 POTENTIAL SIDE EFFECTS
• Monitor vital sign 15,30,60 minute during initial of induction phase
Hemodynamic • Target MAP >65 mmHg favor in the first hour after ROSC
• Monitoring for presences of cardiac arrhythmias

• Control and prevent shivering occurs

Shivering • Perform BSAS (Bedside Shivering Assessment scale )
• Monitor for adequation of sedative and neuromuscular blocker

• Skin integrity should be checked hourly

Skin integrity • Skin massage per 8 hours, change position per 2 hour or if needed THE
• Moisturized cream/oil on contact related skin area per 12 Hour or if needed CRITICAL
ROLE FOR
• All TTM’s patient should have enteral nutrition NURSES
Nutrition • Monitor for peristaltic movement, gastric residual/ GI bleeding
DURING TTM
• Collaboration with dietitians

• Monitor for electrolyte disturbance.

• Any Electrolyte level should be in a normal range.
Electrolyte • Monitor for the sign of electrolyte imbalance including continuous ECG,
• Documentation of urinary output (goal 0,5-1 ml/kg/h)

• Monitor glucose level regularly keep it at normal range 90-110 mg/dl

Glucose control • Check the glucose level hourly
Cardiac Arrest Center

- Expert consensus ACVA, ESC, ERC< ESCIM :

Cardiac arrest centre are 24/7 available of
an on-site coronary angiography,
emergency department, ICU, Imaging
facilities, Echocardiography, Ct & MRI.

- Adult non traumatic OHCA should be cared

for in Cardiac arrest Centres.
 Challenges & Contributing factors

Initiated in ED
Methods Environment

ICVCU
outdated Initiated Other hospitals does
Unavailable
protocol not have
Time equipment/protocol
consume Inter-
Mul.ple
Not meeting diciplinary
department
AHA/ERC leadership
recommendation Improving
MD’s Patient
care
CC Nurses Surface/ IV
Colling

People material

Clear
New protocol
communication
 LIHAT Study
(Lactate Clearance in Heart Arrest)
All Resuscitated Patients Who Received TTM
N=16

budiyanto,R Tri Sulastri 2018 Characteristics Frequency Percent

Age
Number of adult in
q <60 years old 8 50
hospital cardiac Arrest
Cohort study q > 60 Years old 8 50
July 2018- April 2019
Sex
Flow Diagram of Study Pts N = 155 q Male 13 81.3
Enrolled q Female 3 18.7
Non ROSC
N =77 Diagnoses on admission
ROSC q STEMI 8 50
q Heart failure 8 50
N=78
Etiology Cardiac Arrest
Non TTM q Shockable (VT/VF) 9 56.3
TTM
(excluded) q Non Shockable (PEA/Asystole) 7 43.7
N = 60
Excluded: N = 18
In hospital intervention
Muldple comorbidides n= 25 q PPCI 5
Dead during TTM process n= q IABP 1
13 q RRT 2
Poor neurological status q TPM 1
Total Study
before cardiac arrest n= 6 q MULTIPLE 3
Subjects
q No 5
N : 16
(Enrolled) CPR Duration
q < 20 minutes 9 56.3
q >20 minutes 7 43.7
Non Survival to discharge 6 37.5
Survivor
Survivor
N=6 Favorable Neurological Outcome 6 37.5
N= 10
(37.5%)
(62,5%)
THE POST CARDIAC ARREST TEAM

Cardiologist
Intensivist Goal :
Improving
Brain
Rapid Feedback & Favorable
preservation
Response Rehabilitation system outcome
or
team improvement
Hypothermia Cardiac
Critical
Nurse
 PROGNOSTICATION

ü We perform the prognosDcaDon not earlier than 72 hours aGer

ROSC. Average 4-6 Days.
ü All sedaDve and neuromuscular blocker should be stopped.
ü Pupil reflexes, Motoric respond, Body movement, CPC, CT head.
ü The prognosDcaDon process was done by the commiQee of post
cardiac arrest Team including cardiologist, intensivist, neurologist,
cardiac nurse, paDent’s family.
ü Withdrawal/End of life assessment. Provide high quality Dme
between paDent and their family, and paDent’s zero pain.
 CONCLUSION
• After 7 months applying the post cardiac arrest team model, on
adult cardiac arrest survivor had successfully discharge out of
hospital 37.5% with CPC 1-2, but the data was still limited.
• The clinical application of TTM is still challenging, require multi
professional approach to determine the best clinical practice in the
field
• The data still have limitation, Need further investigations with larger
scope. Multicenter? National Concern?
 Take Home Messages
ü TTM means not only temperature but involving pharmacotherapy,
device cooling, and timely neurologic prognostication.
ü We need to focus on early assessment after ROSC using PCAC to
determine 33 or normothermia. Avoid hyperthermia within 72 hour
is essential.
ü Nurses play significant role from preparation, induction,
maintenance, prognostication and recovery.
ü Inter-disciplinary leadership is highly required.
Thank You
 References
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