Therapeutic Hypothermia Protocol for Brain Injuries Paige Whitmire

Therapeutic Hypothermia Protocol for Brain Injuries Paige Whitmire Dietetic Intern 2014 -2015

Background Information “Old” practice ideas to reduce ICP Fluid restriction Use of Mannitol (diuretic) Hyperventilate (decrease CO 2 levels) No feeding due to glucose metabolism risk “New” practices continue to be developed

Overview Patient information Therapeutic Hypothermia Therapeutic hypothermia’s impact on nutrition My patient vs. current research Nutritional assessment based on findings

Patient Selection Learning about a new protocol “Cutting edge” research Opportunity to directly measure resting metabolic rate

Medical Diagnosis Primary diagnosis: subarachnoid hemorrhage Patient’s prognosis: poor Hypothermia could improve outcomes?

Therapeutic Hypothermia Cooling: obtained goal temperature in 7 hours Method of Cooling: External Cooling Gaymar Meditherm Cooled to: 32. 8◦C Duration: 5 days hypothermic Re-warming: 0. 1◦C per hour to 37. 1◦C Obtained in 25 hours

Medication/Paralytics Paralytic Vecuronium: 0. 8 mg/kg/min Sedatives Midazolam: 0. 7 mg/kg/hr Fentanyl: 175 mg/hr 3% saline @ 15 m. L/hr Insulin drip: 3 units/hr KCl: 20 m. Eq as needed

Overview Patient information Therapeutic Hypothermia Therapeutic hypothermia impacts on nutrition My patient vs. current research Nutritional assessment based on findings

Pathophysiology Causes of neurological damage due to stroke or brain injuries Mitochondrial damage Production of free radicals Reperfusion causing further damage

Why hypothermia may work… Hypothermia counteracts multiple steps of cellular injury following acute stroke Reduces oxygen consumption Inhibit free radical formation and inflammatory responses Limit edema Lower the amount of intracellular calcium Exact mode is still being researched

Benefits from metabolic effects Neuroprotective effects by reduction or delay in metabolic consumption during the stress of a CNS injury Reduces CMRO 2 by 5% per degree Celsius 5. 9% reduction in energy Slows lactic acid production to prevent acidosis Lowers metabolic and energy demands Promotes tissue preservation

Methods for Cooling: Surface Cold air, water and/or ice through a thermoconductive blanket Cooling jackets Ice packing Advantages Noninvasive Inexpensive Easy to implement Disadvantages Fluctuations in body temperature Prolonged time to achieve the temperature goal

Methods for Cooling: Intravascular Infusion of ice-cold fluids through intravascular catheters (with metal or circulating cold water– filled balloon conductors) Advantages Shorter time to goal temperature More precise hypothermic control Less shivering Disadvantages More invasive Higher cost

Potential Complications Shivering Pneumonia Decreased cardiac output Hyperglycemia Thrombocytopenia Hypokalemia Loss of gut function Fever

Overview Patient information Therapeutic Hypothermia Therapeutic hypothermia impacts on nutrition My patient vs. current research Nutritional assessment based on findings

Energy expenditure in ischemic stroke patients treated with moderate hypothermia 10 patients treated with moderate hypothermia (33∘C) following an acute ischemic stroke Indirect calorimetry was performed over the first 6 days after admission Mean daily TEE decreased significantly: 1, 549 kcals before initiation of hypothermia 1, 099 kcals the first day 1, 129 kcals the second day 1, 157 kcals the third day Returned to baseline (and 16% above) after hypothermia was terminated

Modification of the Harris-Benedict Equation to Predict the Energy Requirements of Critically Ill Patients during Mild Therapeutic Hypothermia 5 patients suffering from acute cerebral injuries who underwent mild hypothermia Indirect calorimetry measurements: Every 3 -4 hours during cooling/re-warming Every 12 hours during the steady hypothermic state Basal metabolic rate decreased by 30. 3% Every drop in temperature by one degree led to a 5. 9% reduction in energy Measured TEE was 16. 7% lower than calculated TEE

Metabolic Downregulation: A Key to Successful Neuroprotection? Hypothermia slows but does not completely prevent the eventual depletion of ATP Several studies suggest that metabolism is not significantly remarkable in neuroprotection Example: rodents subjected to 20 minutes of forebrain ischemia Brain levels of various metabolites were no different from rats who were in a normothermic state Thus, the influence of hypothermia on cerebral metabolism probably does not fully explain its protective effect

My patient vs. Current Research Hypothermic 4/7/15 Re-warming Day 1 4/8/15 Re-warming Day 2 4/9/15 32. 8◦C 35. 4◦C 37. 1◦C Heart Rate 53 69 74 Minute Ventilation 6. 2 7. 1 6. 3 ICP 19 21 23 1, 950 kcals 2, 440 kcals 2, 755 kcals Temperature Delta. Trac

Equation vs. Calorimeter Hypothermic State (32. 8◦C) 58% above the PSU equation calculation Day 1 Re-warming (35. 4◦C) 51% above the PSU equation calculation Day 2 Rewarming (37. 1◦C) 47% above the PSU equation calculation

Overview Patient information Therapeutic Hypothermia Therapeutic hypothermia impacts on nutrition My patient vs. current research Nutritional assessment based on findings

NCP: Assessment Calories Prior to hypothermia protocol: 2, 475 kcals/day (PSU equation x 1. 1) During hypothermia protocol and medical paralysis: 1, 375 kcals/day (PSU equation) After completion of hypothermia protocol: 2, 440 kcals/day (indirect calorimetry measurement) Protein: 130 g/day (1. 75 g/kg of adjusted body weight)

Alterations during admission Prior to hypothermia protocol Nutren 1. 5 @ 80 m. L/hr (x 21 hours) Beneprotein: 3 scoops/L of feeding Nutrisource Fiber: 2 scoops in 50 m. L of water 4 x/day During hypothermia protocol and medical paralysis Replete @ 70 m. L/hr (x 19. 5 hours) Beneprotein: 5 scoops/L of feeding Nutrisource Fiber: 3 scoops in 75 m. L of water 4 x/day After completion of hypothermia protocol Nutren 1. 5 @ 85 m. L/hr (x 19. 5 hours) Beneprotein: 3 scoops/L of feeding Nutrisource Fiber: 3 scoops in 75 m. L of water 4 x/day

NCP: Diagnosis Increased nutrient needs (energy) (NI- 5. 1) related to therapeutic hypothermia protocol as evidenced by resting metabolic rate calorimetry measurement of 1, 950 calories while in a hypothermic state.

NCP: Intervention Food and or/nutrient delivery (ND) Enteral and Parenteral Nutrition (ND-2) – Enteral Nutrition (ND-2. 1) – Composition: Provided nutrition through the GI tract via keofeed tube based on patient’s calculated protein and measured energy needs.

NCP: Monitoring and Evaluation Indicator: Enteral nutrition intake (FH-1. 3. 1) – Formula/solution Criteria: Patient will receive Nutren 1. 5 @ 80 m. L/hr, Beneprotein 3 scoops/L of feeding, and Nutrisource Fiber 2 scoops in 50 m. L of water 4 x/day in order to meet her calculated protein and energy requirements.

Indicator: Enteral nutrition intake (FH-1. 3. 1) – Formula/solution Criteria: Patient will receive Replete @ 70 m. L/hr, Beneprotein 5 scoops/L of feeding, and Nutrisource Fiber 3 scoops in 75 m. L of water 4 x/day in order to meet her energy requirements during the hypothermia protocol. Indicator: Enteral nutrition intake (FH-1. 3. 1) – Formula/solution Criteria: Patient will receive Nutren 1. 5 @ 85 m. L/hr, Beneprotein 3 scoops/L of feeding, and Nutrisource Fiber 3 scoops in 75 m. L of water four times per day in order to meet her energy requirements after the hypothermia protocol is complete.

Conclusion Limited research Measurement of my patient prior to hypothermia protocol may have given a different result Case-to-case basis Establish measurement in protocol Therapeutic hypothermia may have benefits, but not necessarily nutritionally

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