Therapeutic hypothermia: managment in the highly dependent or critically ill infant or child: using a cooling blanket system (CSZ Blanketrol III)

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Objectives

The use of induced hypothermia as a therapeutic adjunct has been used as a means of improving survival and neurological outcomes following cardiac arrest, cerebral hypoxic-ischaemic events (such as perinatal asphyxia) and following traumatic brain injury (PSCCM 2003Edwards & Azzopardi 2006Meex et al 2013). Hypothermia has also been used in paediatric intensive care to manage infants/children with life threatening arrhythmias such as Junctional Ectopic Tachycardia (Plumpton et al 2005Kelly et al 2010).

There are a variety of ways to cool the body including using a specific cooling/warming system. In this paediatric intensive care unit the current system is the Cincinnati Sub Zero (CSZ) Blanketrol® III. This is a water-circulating system using conductive heat transfer to cool/warm the patient. Induced hypothermia is not without its risks so it is important to obtain medical guidance on when to begin cooling and what ‘set-point’ or temperature range is required (CSZ 2011).

Scope

This nursing procedural guideline is intended to be followed by nurses involved in caring for the highly dependent or critically ill infant or child requiring body temperature management and/or therapeutic hypothermia using the CSZ Blanketrol® III unit within the Paediatric Critical Care Unit at R.H.C. (Glasgow).

Audience

All nursing staff involved in monitoring body temperature and use of therapeutic hypothermia in the Paediatric Critical Care Unit should be familiar with this nursing procedural guideline.

Equipment

CSZ Blanketrol® III Model 233 Hyper-hypothermia unit   - including connecting water hoses

   

CSZ Maxi-therm® Lite (disposable) 
Placed under and/or over top of the infant/child

 

 

Connector cable (blue) probe for use with disposable temperature probes such as the Henley’s REF.4491H.  (non-disposable)           

 

 

Disposable temperature probe (E.g. Henleys REF.4491H)                            

 

 

Non-sterile disposable gloves & apron
Distilled water (if required to fill reservoir in unit)           

 

 

*If using rectal temperature probe then consider securement tape (E.g. Clinifix™)

 

 

Procedure

Recommendations and precautions

Therapeutic hypothermia has been used (in conjunction with other neuroprotective strategies) to improve neurological intact survival in patients following cardiac arrest, perinatal asphyxia and head injury (Battin et al 2003Holzner et al 2005McLivoy 2005Oddo et al 2006Keresztes 2006Tume 2008Rupich 2009). A number of societies have reviewed literature and clinical trials, and have recommended and published guidelines on mild therapeutic hypothermia after resuscitation from cardiac arrest (Nolan et al 2003Paediatric Advanced Life Support: Resuscitation Council UK 2015).

However there is insufficient evidence to fully recommend the use of therapeutic hypothermia in paediatrics, although preliminary data involving trials in perinatal asphyxia support its use as feasible and safe. In paediatric traumatic brain injury there is also evidence to support the avoidance of hyperthermia and use of cooling to maintain body temperature below 37.5° and thus avoid the poor neurological outcome of hyperthermia (PSCCM 2003Tume 2008Rupich 2009Alder Hey 2011Meex 2013).

Hypothermia can decrease the automaticity of the heart and reduce sympathomimetic catecholamine levels. Therefore despite limited evidence, induced mild hypothermia (along with Amidarone, pacing and cardioversion) has been used effectively in paediatrics to manage life-threatening arrhythmias such as Junctional Ectopic Tachycardia (Bash et al 1987Dodge-Khatami et al 2002Plumpton et al 2005Kelly et al 2010Kidson & Lafferty 2011).

However, despite the documented benefits of therapeutic hypothermia it must be remembered that there are significant risks associated with hypothermia. These include alterations in coagulation with increased risk of bleeding, increased risk of wound infection and bradycardia with decreased cardiac output and increased systemic vascular resistance. Other serious side-effects the nurse must be alert to include alterations in drug metabolism, fluid and electrolyte imbalances, decreased insulin sensitivity and insulin secretion (Polderman & Herol 2010).

If the infant or child is awake then induced hypothermia can result in increased discomfort, shivering (in the older infant & child) with associated increased oxygen consumption. As a result of this it is important that the nurse ensures any infant or child undergoing therapeutic hypothermia (<35ºC) is properly sedated and paralysed with neuromuscular blockingmedicines, otherwise shivering may still occur (Kidson & Lafferty 2011).

References

Alder Hey (2011) Medical and Nursing Management of Traumatic Brain Injuries in Intensive Care – Guidelines and ICP Management Algorithm. Alder Hey Childrens NHS Foundation Trust, Liverpool

Bash, SE Shah, JJ Albers, WH Geiss, DM (1987) Hypothermia for the treatment of postsurgical greatly accelerated junctional ectopic tachycardia. Journal of American College of Cardiology, Vol. 10 (5), pp 1095-1099.

CSZ Cincinnati Sub-Zero Products Inc. (1982) Blanketrol® III Operation Manual, Cincinnati.

Dodge-Khatami, A Miller, OI Anderson, RH Gil-Jaurena, JM Goldman, AP de Leval MR (2002) Impact of junctional ectopic tachycardia on postoperative morbidity following repair of congenital heart defects. European Journal of Cardio-thoracic Surgery, Vol. 21, pp. 255-259.

Edwards, AD Azzopardi, DV (2006) Therapeutic hypothermia following perinatal asphyxia. Archives of Disease in Childhood Fetal Neonatal Edition, Vol. 91, pp 127-131.

Holtzclaw, B (2004) Shivering in acutely ill vulnerable populations. AACN Clinical Issues: Advanced Practice in Acute and Critical Care, Vol. 15 (2), pp 267-279.

Holzer, M Bernard, SA Hachimi-Idrissi, S Roine, RO Sterz, F Mullner, M (2005) Hypothermia for neuroprotection after cardiac arrest: Systematic review and individual patient data meta-analysis. Critical Care Medicine, Vol. 33 (2), pp 414-418.

Kelly, BP  Gajarski, RJ  Ohye, RG  Charpie, JR (2010) Intravenous induction of therapeutic hypothermia in the management of junctional ectopic tachycardia: a pilot study. Pediatric Cardiology, Vol. 31 (1), pp. 11-17.

Keresztes, PA Brick, K (2006) Therapeutic hypothermia after cardiac arrest. Dimensions of Critical Care Nursing, Vol. 25 (2), pp 71-76.

Kidson, C Lafferty, N (2011) Postoperative Junctional Ectopic Tachycardia (JET) Guideline. NHSGGC.

McIlvoy, LH (2005) The effect of hypothermia and hyperthermia on acute brain injury. AACN Clinical Issues: Advanced Practice in Acute and Critical Care, Vol. 16 (4), pp 488-500.

Meex, I Dens, J Genbrugge, C Jans, F DeDeyne, C (2013) Therapeutic hypothermia after cardiac arrest: yes, but who, when and how? International Journal of Intensive Care, Vol.20 (3), pp. 93-98.

NHS Greater Glasgow Prevention and Control of Infection Manual (2004) NHS Greater Glasgow Control of Infection Committee Policy. NHS

Nolan, JP Morley, TL Vanden Hoek, TL Hickey, RW Kloeck, WGJ Billi, J Bottiger, BW Okada, K Reyes, C Schuster, M Steen, PA Weil, MH Wenzel, V Carli, P Atkins, D (2003) Therapeutic hypothermia after cardiac arrest: An advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation. Circulation: Journal of the American Heart Association, Vol. 108, pp 118-121.

Oddo, M Schaller, MD Feihl, F Ribordy, V Liaudet, L (2006) From evidence to clinical practice: Effective implementation of therapeutic hypothermia to improve patient outcome after cardiac arrest. Critical Care Medicine, Vol. 34 (7), pp 1865-1873.

Pediatric Society of Critical Care Medicine (2003) Guidelines: The role of temperature control following severe pediatric traumatic brain injury. Pediatric Critical Care Medicine, Vol. 4 (3), Suppl. July, pp S53-55.

Plumpton, K Justo, R Haas, N (2005) Amiodarone for post-operative junctional ectopic tachycardia. Cardiology in the Young, Vol. 15, pp 13-18.

Polderman, KH Herol, I (2009) Therapeutic hypothermia and controlled normothermia in the intensive care unit: Practical considerations, side effects and cooling methods. Critical Care Medicine, Vol. 37 (3), pp 1101-1120.

Resuscitation Council (UK) (2015) Paediatric Advanced Life Support Guidelines

Rupich, K (2009) The use of hypothermia as a treatment for traumatic brain injury. Journal of Neuroscience Nursing, Vol.41 (3), pp. 159-167.

Scott, EM Leaper, DJ Clark, M Kelly, P (2001) Effects of warming therapy on pressure ulcers - a randomised trial. AORN Journal, Vol. 73 (5), pp 921-938.

Schouchoff, B (2002) Pressure ulcer development in the operating room. Critical Care Nursing Quarterly, Vol. 25 (1), pp76-82. 

Tume, L (2008) A review of the intensive care management of severe paediatric traumatic brain injury. British Journal of Neuroscience Nursing, Vol. 4 (9), pp. 424-431.

Editorial Information

Last reviewed: 01 November 2016

Next review: 01 November 2018

Author(s): Jeanette Grady

Approved By: Clinical Effectiveness

Reviewer Name(s): PICU Clinical Guideline Group