Improving temperature management post-cardiac arrest in a District General Hospital Intensive Care Unit

Regina Askary, Ben Whittaker, Adam Revill

• NHSambulancesattend 30,000 out-of-hospitalcardiacarrests(OOHCA) inthe UK eachyear with a9%survivalrate.

• Return of spontaneouscirculation (ROSC) is achieved in approximately 30% with the majority beingunconscious and needingICU admission,and with only 30-50% being dischargedalive.

• Therapeutichypothermia showed promising results in significantclinicaltrialsandwas the management of choice for manyyears but the recent TargetedTemperatureManagement2 (TTM2)trial concluded that there was nobenefit to cooling patients to 36°C following OOHCA if the arrestwas due to cardiac/unknowncause.

• Our localguidance untilknow suggested thatpatients post-ROSCshould be maintainedat 36°C orbelow for the first 36 hours followed by preventionof pyrexia (defined as>37° inthe localguidance) for the following 36 hours.Regulartemperature monitoring is essential to achieve this

Aim Outcomes measured

The aim of this auditwas to comparecurrenttargeted temperaturemanagementatTorbay ICU with the hospital andnationalguidance, reviewing adherence to maintaining 36°C through invasive cooling and fever prevention to improve how we care for patients post-cardiacarrest.

Data collection

Theincluded dataruns from February 2020 to March 2022, collected via the Torbay ICUonline database.

Exclusion criteria:

• In-hospitalcardiacarrest

• Cardiacarrestsecondary to non-cardiaccauses

• Conscious patients following verbalcommands post ROSC

• Temperature<30°C on presentation

• Systolic BP <80mmHg despite adequatesupport (fluid loading,inotropes/balloonpump)

• Intracranial bleeding

• Severe COPD with LTOT

• Pregnant or presumedpregnant

1. Whether regular temperature management was recorded

2. Adherence to 36°Cfor 36h

3. If pyrexia was avoided for the following 36 hours (through use of invasive cooling and regular antipyretics)

Results

A total of 39patients were identified over the 2year period: 39participants withappropriate data for the first 36hours

18 patients who made it past 36h (up to 72h) requiring temperature management

89.7% hadt>36°C

61.5% hadt>36°C for at least2 continuous hours

30.8%received invasive cooling

38.5%receivedregularparacetamol

• 16.7%hadallhourlytemperatures recorded but most (77.8%)had them recorded the majority of the time (majority defined as>90%)

• 20.5% were 36°C orbelow appropriatelymost of the time.

• We were able to prevent t>37 °C in just 22.2% of patients who made it past the initial 36h.

How can we improve our care?

Recent guidance from ERC-ESICM has confirmed that avoidance of pyrexia (defined as 37.8°andabove) is the new aim post cardiac arrest

1. We propose to improve temperature monitoring in these patients, and reduce pyrexia through regular paracetamol and earlier initiation of invasive cooling

2. We are updating our hospital guidance in line with these recommendations to make this information freely available to staff.

3. Education for nursing staff and doctors will be undertaken through clinical effectiveness meetings, journal clubs, MDTs and reminders through admission paperwork and handovers for temperaturetargets when these patients are present on the unit.