therapeutic hypothermia exclusions

Inclusion Criteria:

1. Cardiac arrest with return of spontaneous circulation.
2. Persistent coma after return of spontaneous circulation.
3. Adequate blood pressure can be maintained either spontaneously or with fluids/pressors.
4. Known time of cardiac arrest (downtime less than 1 hr).

Exclusion Criteria:

1. Coma due to identifiable reason other than the cardiac arrest.
2. Responsive to verbal stimuli after cardiac arrest.
3. Pregnancy
4. Terminal illness
5. Coagulopathy or active bleeding (will consider patients who were anticoagulated before arrest).

ya, that patient won't be cooled here.

I'm very curious (as a new ICU nurse) as to why this is an exclusion criteria?

Therapeutic hypothermia after cardiac arrest has been shown to improve neurologic outcome. This was supported by numerous studies in both out of hospital and in-hospital cardiac arrests initially in Europe and later in the US. Because the goal is to measure its effect on neurologic outcome, the studies only included patients who did not have a significant neurologic response following return of spontaneous circulation after resuscitation efforts were provided. It makes sense to do that because these are the patients that will benefit from the therapy. Patients who awaken after resuscitation have no neurologic sequelae to begin with.

For additional read: Therapeutic Hypothermia After Cardiac Arrest

Notice that the ILCOR recommendation (2002) was for patients whose initial rhythm was V fib. The early studies were on this particular subset of survivors of cardiac arrest. There are newer studies that have shown benefit in other cardiac arrest presentations and the therapy is now widely used for any patient who went into cardiac arrest regardless of presenting rhythm.

Exclusion criteria at my facility:
-CPR > 45 minutes
-Unwitnessed asystolic or PEA cardiac arrest with CPR and/or ACLS for more than 15 minutes
-Arterial O2 saturation < 85% for > 15 minutes after return of spontaneous circulation despite supplemental O2
-Refractory shock/hypotension (MAP < 70mmHg) despite IV fluids and vasopressors
-Recurrent ventricular fibrillation or refractory ventricular tachycardia in spite of appropriate therapy
-Severe coagulopathy, with clinical evidence of bleeding and/or platelets less than 30 x 10˄3/mm˄3
and/or INR > or equal to 2.5 (note: cooling causes coagulopathy)
-Other causes of coma (consider CT Scan, MRI, EEG if clinically indicated)
-Persistent seizures
-Unfavourable comorbidity

Ideally, the answer should be "no" to all of the above in order to proceed with therapeutic hypothermia