During the 2019 Therapeutic Hypothermia and Temperature Management Symposium in Miami, state-of-the-art lectures on the current advances in the use of temperature management were conducted. Dr. Gretchen M. Brophy moderated a session on targeted temperature management (TTM) in nursing care. An outstanding lecture was given by David A. Hildebrandt on establishing and managing a TTM program in the hospital. Elizabeth A. Moore lectured on establishing an Extracorporeal Membrane Oxygenation program from a nursing perspective. Finally, Todd J. Van de Bussche provided a very personal story on his experience with hypothermia in terms of the patient perspective. All these presentations were outstanding and stimulated a rich discussion among the attendees of the conference.
Question: I was curious if all hospitals use some sort of bispectral index (BIS) monitoring throughout the cooling phase?
Mr. David A. Hildebrandt: Some do and some do not. At our particular institution, we are not using it currently. There is no evidence that it is accurate. If you turn the BIS monitor on in the room, it would show some waveform alone because of all of the other monitors in the room.
Dr. Gretchen M. Brophy: In postcardiac arrest patients, we must consider nonconvulsive status epilepticus as well. Therefore, we will initiate continuous electroencephalogram (EEG) monitoring, which is much more accurate than BIS monitoring.
Dr. Gretchen M. Brophy: I have a question about patients who are do not resuscitate (DNR), as this is not something I think about initially as a pharmacist, but I know you as nurses always do. Is it common to have stipulations for cooling DNR patients or how do you approach these patients?
Mr. David A. Hildebrandt: It is very controversial but you think about a DNR patient who gets resuscitated. The emergency medical service comes out to the house and the family gets nervous and calls 911, they cannot produce the papers and the patient gets resuscitated and some of them can be awake but not fully functional when they arrive to the emergency room (ER) and you extubate them and they survive and you do let them go for days and you cool them because they might have a better outcome versus if they did not get cool. For those who arrest and they are down long, families understand that they are DNR and then they are given comfort care. There are rare situations when it might be ok for them because they did not have any comorbidities but that they are just DNR. The family gets nervous and they call 911. It has been done is some circumstances but it is very controversial.
Dr. Gretchen M. Brophy: Do any of you have specific questions built into your targeted temperature management (TTM) protocols to ask about DNR status or whether the family would like any advanced therapy such as TTM?
Comment: It is true that families sometimes get very anxious and they call 911 even though it has been fully described that their loved one does not want to be resuscitated. We have occasionally induced patients into hypothermia and then discovered that they are DNR. We will rewarm them slowly and let the chips fall as they may. I also wanted to mention something to the person who asked about the BIS monitor. We know that the BIS monitor was designed particularly for anesthesia and not for the intensive care unit (ICU) and has not had any support for evaluating neurologic function or even truly appropriate sedation, so the recommendation is to use continuous EEG monitoring that will allow you to evaluate both seizure and shiver and really help you with those subclinical patients. I really want to say how much I appreciate what you have said. Each one of you have said something so exquisite and really important to our practice and just want to say thank you.
Question: I have a question for David and Elizabeth, how long did it take you to get your program from the start to where you felt like it was working well?
Ms. Elizabeth A. Moore: Literature supports that it takes ∼3 years for culture change so I would say 3–5 years to go from a neonatal and pediatric Extracorporeal Membrane Oxygenation (ECMO) program to truly implement a well-functioning adult program. It was not until that cold and flu season hit in 2009 that we were getting everything humming on all cylinders.
Mr. David A. Hildebrandt: We have a robust program but it is still a challenge every single day. We are a teaching institution, residents rotate every 4–6 weeks so it is a constant to keep the program up and running.
Comment: We also do not use the BIS monitor at our institution but just to point out in the literature there have been a couple of good reports from Maine Medical on using the BIS monitor as a shivering detection tool and it looks to be very accurate. It looks to be very appropriate to use in my estimation in patients who are undergoing hypothermia treatment for cardiac arrest. It is important to recognize that they preferentially paralyze patients to help eliminate some of the background noise you are talking about with the BIS. They are using the BIS monitor that gives you a quantitative EMG signal, so having looked at their studies and reviewed their data, I think it is something that you could use as a shivering detection tool. To Gretchen's point, it does not take away the importance of looking at EEG and have continuous EEG monitoring in the arrest patients, but it is a tool that you can use. There is literature out there supporting it.
Comment: I wanted to go back to the DNR statement. As a neurointensivist who is called to cool or not cool in these patients, I want to remind everyone that DNR is not synonymous with do not treat so the resuscitation has already happened. Although I hope that everyone has a clear pulse and we can treat patients, but at Cedars Sinai we take the DNR into consideration after we have cooled them, then rewarmed them. We can then make decisions if they have a poor outcome whether to withdraw care at that point. The considerations that we do consider are whether they have terminal cancer, or something that precludes achieving the optimal cognitive outcomes that have been studied with cooling 6 months out. I just want to emphasize that DNR does not mean do not treat.
Question: Could you speak to the emotional impact of postcardiac arrest with either you or your family's symptoms of posttraumatic stress disorder (PTSD)?
Mr. Todd J. Van de Bussche: It is funny that you should bring that up. Knowing myself and as a program we are just starting to look at. I know myself that there is something there but I am not sure whether it can be classified as PTSD. I have experienced an event but unlike PTSD patients, I do not remember the event. We are now starting to see quite a few patients and I am 11 years out and some of these emotions are now just coming to the forefront and I am not the only one having these. Ironically enough, I was talking to our hypothermia coordinator and we are starting to now see these patients are now anywhere from 5 to 10 years out from their event. There is anxiety, depression, we do not know why and I do not know why. I cannot put my finger on it. I know there have been personality changes. I used to be a very laid back easy going person, but it can be my birthday and one person says something out of character and I get pissed, but I do not know what it is. I do not know whether it is a secret word that sets it off but something sets me off. I told our coordinator about this and she says you are about the 10th person who has come to me about this. So, I ask you guys if you have programs, then you should look into this as well.
Question: You had mentioned that before your cardiac arrest you were taking Bendryl and Tylenol, what was the significance?
Mr. Todd J. Van de Bussche: That is what they are attributing my arrest to is that my antihistamine gave me a prolonged QT (time from the start of the Q wave to the end of the T wave) segment and I had an R-on-T phenomenon. That is the only thing they are basing my cardiac arrest on. They talk about the repetitive questioning and I had friends at my bedside and they were getting tired of this and they said I was dancing in pink tutus, that is probably what my trigger is now.
Question: I have a question about ECMO. Is there a minimum number of patients per year whom you need to see to maintain competency of staff?
Ms. Elizabeth A. Moore: We review quarterly our extracorporeal membrane oxygenation (ECMO) specialist pump hours. Just based on volume, we would like to hit at least two shifts every quarter. That is bare minimum, so to counter that, we have a pretty robust simulation program where we conduct in situ simulations with the team. Every quarter we have the equipment out to practice technical skills on. We historically had 20 to 25 patients per year but now we have 75–100 patients per year. The experience is there because the patient volume is there.
Question: What suggestions do you have for putting the fire under the doctors to get them to initiate TTM at the hospital?
Mr. David A. Hildebrandt: Are you in a program now that does not use TTM?
Comment: We have a program but it feels like every time we get a patient who comes through, they are like let us try 33°C today or let us try 36°C. I do not understand why we would choose one versus the other when both patients are cardiac arrest patients, have stents in the right coronary artery (RCA), and ironically they are both the same age.
Question: Why would we choose one or the other? Why cannot we standardize it?
Mr. David A. Hildebrandt: Do you have a program with team members who meet regularly to discuss these things and develop not only your protocol but also review all of your cases?
Comment: We just started it.
Mr. David A. Hildebrandt: I think that is the key and then develop your data and showing your data to these physicians and getting them on board with the help of other physicians who know what is important about the TTM program.
Question: Could you say what was most important to your family's experience during your stay at the hospital and what do you wish somebody had not said to them?
Mr. Todd J. Van de Bussche: Luckily for me I was part of the flight team and so my family was there. We are a big family. Like I said, when I had my arrest, my babysitter who normally watches my stepson was called by my wife and she went over to the hangar and told the flight team that Todd just had a cardiac arrest and you need to be with Beth. Both my wife's family and my family live out of town, so there was not going to be any immediate family there immediately so they did not leave my wife's side for that time. As for the downside, it is probably more for me that my wife has no recollection or concept of what she did. I think that is harder for me, you saved my life and I would not be sitting here if it was not for her and you guys either. She had the support and that was probably the biggest thing and I think that in institutions you have your social workers there and you have people but one of the other things I would suggest is have some cardiac arrest survivors come in and talk to your patients. I know I have done that a few times and I talked to the families. I tell them I do not have a magic ball but I have been there and done it myself and this is the result.
Question: Thank you Todd for sharing your story. Can you please share some insight regarding what the first few months of recovery were like posthospital discharge?
Mr. Todd J. Van de Bussche: For me, like I said, I was working on CAMES at the time so I had something to do after I got out of the hospital. I had an unusual recovery in some aspects. I had a pacemaker and defibrillator put in and needless to say I got discharged from the hospital and I was back in the hospital 2 days later with excruciating chest pains. My pacemaker wire had come out. They had to go back in and fix the wire and I was in the hospital for 2 more days. I go home and the area where the pacemaker is getting warm and then it is red and luckily it was just a small spot infection and after that I think that helped with my physical recovery. That took ∼2 weeks and I was back to what I thought was a productive mental state. I still had some short-term memory issues but I was able to function and I had a project to do. Virginia has a law that if you have had a seizure or have been unresponsive, you cannot drive for 6 months, so I was going stir crazy for 6 months, but this did give me time to do my project. I will say at 6 months and a day, I went back to the flight line. People would pick me up and I would do protocol test to make sure I was clear. Ironically enough, the first patient whom I took care of when I returned was a patient who was in postcardiac arrest.
Dr. Gretchen M. Brophy: For patients who are in the ICU, on ECMO, undergoing TTM, postcardiac arrest, or experiencing any stressful event, we talk about the post-ICU syndrome. What we are trying to utilize in the neuro world is diaries and different tools for our patients and families to help them recall what has happened in the ICU. Have you implemented anything at your institution to help with the post-ICU syndrome?
Ms. Elizabeth A. Moore: Not yet but the conversations have begun. The latest trend is awake ECMO. The goal is to have them walking and interactive in their rehab and recovery process. We knew that physically there was benefit but now a few years out there are many psychological challenges that are emerging. Right now there is not a lot of information or best practices for post-ICU syndrome of ECMO patients. It is clear more work needs to be done to best understand how to support their psychological healing as well as physical.
Dr. Gretchen M. Brophy: Have you implemented anything like music therapy and normalizing the patients by giving them their glasses, hearing aids, etc. in your institutions? Have you done that as well?
Ms. Elizabeth A. Moore: Yes we have.
Question: Todd, I know that we have talked in the past about this. A number of patients have mentioned this, the “you are so lucky” comment that every postarrest patient hears from the doctors, nurses, and friends, meanwhile you are having some anxiety, nightmares, and your family interactions are not the same. Is there any other phrasing we can use in the health care environment for those patients who are in fact, but may not feel, lucky with all of the new things that are going on in their brain?
Mr. Todd J. Van de Bussche: I cannot really think of any real key words. I think the other things that we do and I know that some is health insurance driven, I know some is just practices and kind of like we were talking about, I went back into the hospital a couple of times. About 6 months later, I go to the doctor's office and she does a 12-lead on me and she says you are good, we are done. Wait a minute, I was dead 6 months ago, what is going on here. I am just looking out for my own personal aspect of it. It is a pain in the butt that I have to go to the Electrophysiology (EP) laboratory and have them put on the ‘hockey puck’ every year but realistically and that is what drives me a little up the wall, as you know with cardiac devices these days we monitor them and we can tell when things go off. I have not had anything and for me that is hard for me to digest.
Question: I was just wondering, you read about the cost of devices these days and protocols and personnel issues. Do you get push back from hospital administrators about initiating these types of programs that may cost a little bit more?
Ms. Elizabeth A. Moore: I think the answer is yes. With ECMO and the reason I bring this up even with my hospitals experience, there is a real discussion of what areas need to grow and what areas need to shrink and part of the impetus for my own personal journey and getting the MBA was the impact of H1N1 in 2009–2010. We did a lot of ECMO in that season that was not financially favorable for the hospital, but we saved many lives. I was called into many meetings wherein hospital administration had sticker shock. To be honest, as a nurse manager of an ECMO program, I could not speak the lingo, explain the benefits of what we were doing clinically, and financially how to justify a program like this. I pursued an MBA so to really digest the financial implication for utilizing high-cost resource medical/medicine treatment plans. I think we would be remiss not to believe that the Centers for Medicare and Medicaid Services (CMS) ruling in October is the first step of governmental regulation of high-cost medical devices much like what we experienced with the ventricular assist devices (VADs). There are very regimented requirements around VAD programs. I think it will come for ECMO too. I think CMS will have to roll back some, what they did with the diagnosis related groups (DRGs), but I believe regionalization of resources will happen with payment model changes.
Question: Todd, how many weeks of rehabilitation or what types of rehabilitation did you undergo?
Mr. Todd J. Van de Bussche: When I did wake up, I was neuro intact and the only thing I had was repetitive questioning for that 6 hours postarrest and some short-term memory issues. While I was still in the hospital, I was there for ∼3 days after I woke up and we did some cognitive tests, but realistically, at that time that was it. Physical and occupational therapy would also come in and talk to me and perform a few tests which I passed. I know since that time we have done some other more labor-intensive testing that goes on with our patients, but then again I was so early in the process and our program was just a couple of months old. I do not think many of those ancillary departments were brought in at that juncture.
