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TRANSCRIPT
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Physician Utilization of Therapeutic Hypothermia
Following Resuscitation from Cardiac Arrest
James W. Rhee, MD
April 29, 2004
The University of Chicago
Emergency Medicine Residency
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Introduction
• Cardiac arrest– Greater than 90% mortality rate– No significant decline over past few decades
despite new drugs and improved access to electrical defibrillation
• Return of spontaneous circulation (ROSC)– Many patients go on to die during subsequent
hospitalization– Neurologic impairment often remains as a
lasting morbidity
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Studies
Hypothermic Normothermic
Alive at 6 months with favorable neurologic status
53% (75/136) 35% (54/137)
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ILCOR Advisory Statement
•Unconscious adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32°C - 34°C for 12 - 24 hours
•Possible benefit for other rhythms or in-hospital cardiac arrest
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Current Use
• Physician Utilization– Physician utilization of therapeutic
hypothermia following ROSC after cardiac arrest remains unclear
• Physician Experience– Initial experiences with hypothermia
• Guide future investigations• Development of critical pathways
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Survey
• We conducted an internet-based survey of U.S. physicians in emergency medicine, pulmonary/critical care, and cardiology – Evaluate physician utilization of hypothermia
therapy– Assess physician opinions and experience
regarding induced hypothermia after cardiac arrest
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Methods
• Institutional Review Board approval
• Health Insurance Portability and Accountability Act of 1996 – compliant
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Methods
• 2000 electronic mail addresses randomly chosen– American College of Emergency Physicians– American Thoracic Society– American Heart Association
• Invitation to participate in survey sent to each address with a hyperlink leading to the survey itself
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Methods
• Survey published via commercial survey provider (Infopoll.com, Dartmouth, Canada)
• Survey comprised of twelve questions– Demographic information
• Field of practice, geographic location, level of training, etc.
– Use of induced hypothermia• Methodology, reasons for non-use, etc.
– Free response at end of survey
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Methods
• Results compiled by survey provider software
• Analysis and tabulation performed using a spreadsheet application (Excel, Microsoft Corp., Redmond, WA)
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Results
2000 emails
1400 hits
265 responses (19%)
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Demographics
Level of Training Practice location: staffingAttending 94% Residents and students present 79%Resident 3% No residents or students present 21%Fellow 3%
Practice location: hospital typeField of Practice Tertiary Academic Hospital 56%Emergency Medicine 41% Referral Hospital 22%Critical Care 13% Community Hospital 19%Cardiology 24% Other 3%Other 22%
Cardiac arrest patients treated per year:Practice location: hospital size up to 5 patients per year 24%More than 1000 beds 4% 6-10 patients per year 30%751-1000 beds 19% more than 10 patients per year 47%501-750 beds 17%251-500 beds 37%up to 250 beds 23%
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Demographics
9%
27%
13% 20%
30%
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Use of Therapeutic Hypothermia
Yes 13%
No 87%
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Critical Care
(n=33)
Cardiology
(n=64)
Emergency
Medicine
(n=109)
All respondents
(n=263)
Yes No
5% 95%
11% 89%
29% 71%
13% 87%
Use of Therapeutic Hypothermia by Clinical Specialty
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Not enough data
Haven’t considered it
Not in ACLS guidelines
Too technically difficult
Current methods cool too slow
Unsatisfactory initial attempts
0% 10% 20% 30% 40% 50%
Reason for nonuse- Percentage of respondents
49%
32%
32%
19%
9%
4%
Reasons Against Use of Hypothermia as a Therapeutic Tool
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Cooling Technique
Cooling blankets
Ice / cold liquid packing
Ice / cold liquid gastric lavage
IV cooling catheter
Cooling mist
Other method
0% 10% 20% 30% 40% 50%
Cooling technique Percentage of respondents
50%
15%
13%
2%
2%
17%
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Free Response
Have not heard of this treatment option 3
Resistance from hospital or other physicians 3
I am interested in technique, want to learn more 3
Plan on using it in the future -- now developing protocol 7
Literature not yet convincing 4
Lack of training -- too many resources required 5
Total number of free responses 80
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Hypothermia Not Yet Incorporated
• Physicians have not yet incorporated the use of therapeutic hypothermia after cardiac arrest despite strong data and published guidelines recommending its use
• This conclusion appears to be consistent across the three specialties queried
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Limitations
• Reflects practice at one point in time
• Selection bias – respondent population was skewed towards physicians practicing in larger hospitals and teaching institutions
• Western US not as well represented
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Best Case
• As physicians at academic institutions and tertiary or referral hospitals were overrepresented – likely represents best case of current practice– Assume utilization of this new treatment
modality in the greater medical community will be less than in larger academically-oriented hospitals
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Reasons for Lack of Incorporation
• Physicians not aware of strong literature supporting use of induced hypothermia
• Not part of standard guidelines– Advanced Cardiovascular Life Support
(ACLS)
• Technical constraints
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Actions to Promote Use
• Physician education• Update ACLS• Share experiences
and protocol development
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Future Technology
• Novel coolant fluids• Cold IV fluids• Cooling catheters
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Research
• Method• Timing• Mechanism
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Summary
• Physician use of hypothermia induction in patients resuscitated from cardiac arrest is low
• Reasons why physicians have not used hypothermia include lack of awareness of supporting data, technical constraints, and the lack of hypothermia protocol incorporation into ACLS
• Better understanding of the pathophysiology of resuscitation and the injury processes on which hypothermia acts will serve to further promote the use of this promising method to save lives
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Acknowledgements
Ben Abella, MD
Annie Hueng
Lance Becker, MD
Terry Vanden Hoek, MD
Lynne Harnish
ERC