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This is a discussion on Therapuetic Hypothermia in MICU / SICU Nursing, part of Critical Care Nursing ... Usiing TP where I work for post code paitients. Question has come up how long the warming phase...by kaiser0926 Apr 7, '12Usiing TP where I work for post code paitients. Question has come up how long the warming phase should be. What is the time frame where you work. Have you had any successful cases. We have had a few patients code during re-warming and I think it is because they are warmed too fast. Any advice/suggestions
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- Apr 7, '12 by ShaunESWe cool for ~24 hours, then passive rewarm with space blanket aiming for 0.5 degree celcius/hour. We remove blankets and recommence cooling if they exceed this.
We've had several successful cases, but we've also had several unsuccessful cases.
Have to be careful with potassium shifts during the temperature shifts, make sure you're doing regular ABGs and slow their warming if they are becoming hyperkalemic.
- Apr 8, '12 by MikeRNWIWe do the same in my ICU. We use a coolguard femoral or subclavian line, which has 5 lumens, 3 for infusion of medications, and two closed circuit lumens that circulate water. Cool as quickly as possible to get down to 31-32 degree C. Once at goal temperature, keep cooled for roughly 24 hours.
When beginning to rewarm, we shoot for .5 degrees C an hour. The coolguard machine can actually control the speed of rewarming, it has to be connected to a core temperature source. As mentioned before, the most important part is watching for ectopy and electrolyte imbalances.
- Apr 9, '12 by BelgianRNSame here our hospital uses either the Arctis Sun system or Coolgard for cooling and rewarming. We try to tolerate potassium levels as low as we can, sometimes <3 mmol/l if our patients remain with stable rhythms.
Our rewarming strategy is not evidence based, but experience based.
If they have received large amounts of potassium due to rhythm problems or if they received huge dosages of insulin (e.g. > 20 units/hour for hours on end) we will rewarm them at 0,15 °C/hour. This number is based on roughly 1° per shift of 8 hours.
If they haven't received a lot of potassium we rewarm at 0,5 °C/hour.
I personally run ABG's evey hour - 2 hours to monitor the potassium shift and adjust rate of rewarming appropriately.
Over the years we've had many successes and many fails. We see a lot of patients for post-resuscitation care. I personally disagree with the trend nowadays where some of our intensivists stop all sedatives first to see if the patient responds, wait for an hour and then start cooling only if not fully awake or not completely areactive.
I feel too much time is lost with this approach. Since some patients spend hours in the cathlab too etc we are already behind schedule.
- Apr 11, '12 by jcmelhornLike others have said, we use the coolguard at our Hospital. We cool for 24hrs at 32C and then rewarm 0.5C/hr. Coolguard does a pretty good job controlling this.
Now, I know you have to be careful not to rewarm to fast. However what is the rationale behind that especially with the K levels? This protocol is fairly new to our unit.
- Apr 12, '12 by VespertinasQuote from BelgianRNThat can't be right. There has got to be a decision tree that's better than this lolI personally disagree with the trend nowadays where some of our intensivists stop all sedatives first to see if the patient responds, wait for an hour and then start cooling only if not fully awake or not completely areactive.
- Apr 12, '12 by BelgianRNQuote from VespertinasYeah there is, it's called being pro-active ^^. "Oh gosh sorry you wanted to evaluate him first? I must have missed that... Oops well he is cooled now I'm sorry. It is a shame to reheat them now...".That can't be right. There has got to be a decision tree that's better than this lol
I mean what's 24 hours anyway it gives ample time to prepare the family for the worst and it doesn't lead to veggies where you keep wondering what if they were cooled.