Therapeutic Hypothermia: Miracle on Ice
|Richard DiLorenzo (left) is guarded by his buddy Wayne Rickey during a friendly game of basketball. Last year, Wayne was "on guard" when Richard suffered cardiac arrest on the same basketball court. Now, after a remarkable journey of recovery, including hypothermia treatment and bypass surgery, Richard is back in the game.
To Richard DiLorenzo, Friday, Jan. 22, 2010, didn’t feel different from any other day. But, that was the day his heart stopped beating.
As part of his weekly routine, the 64-year-old headed to the Kettering Recreation Center to play a little basketball with other retired friends. Not long into their playing time, the men sat down to rest. Without warning, the day took a dramatic turn.
The healthy and active 168-pound man suddenly fell forward from his bleacher seat and bumped his forehead on the wooden floor. He had suffered a major heart attack and subsequent cardiac arrest.
His basketball buddy and a tennis player started chest compressions on him. And three Kettering firefighters – who happened to be exercising nearby – heard the 911 call over the PA system.
They retrieved their automated external defibrillator, jolted Richard’s heart back to life and rushed him to Miami Valley Hospital.
Although Richard’s heart had been revived, he was still at risk for severe brain damage from the lack of oxygen when his heart had stopped. Fortunately for him, he was taken to MVH where he would undergo therapeutic hypothermia.
One month before Richard’s event, MVH had implemented an innovative method to preserve the neurological function of certain cardiac arrest patients. The procedure, called therapeutic hypothermia, artificially lowers the core body temperature of a patient by up to six degrees. Patients who remain in that state for at least 12 to 24 hours after the heart is restarted have a better chance of walking out of the hospital with a good neurological outcome than those who do not have the treatment.
The effect of therapeutic hypothermia varies in each patient, but for Richard, it had incredible results. A week after undergoing quadruple bypass surgery, he left the hospital as mentally fit as the day he headed to the gym. Four months later, he walked back onto the basketball court almost as if the incident had never happened.
“I am delighted that they chose to use therapeutic hypothermia because everything turned out so well,” says Richard. “And my recovery from heart surgery has been excellent.”
A Cooling Trend That’s Heating Up
Richard realizes he’s one of the fortunate ones. Only 20 percent of patients who have been resuscitated after experiencing cardiac arrest live. And many of those who do survive suffer varying degrees of brain damage.
The damage starts within minutes after cardiac arrest, when blood stops pumping to vital organs, especially the brain. The damage gets even worse when the blood flow is restored, causing swelling around the brain and setting off a chemical reaction that can actually kill brain cells.
|Andie Slivinski, CNS, demonstrates how a cooling kit is used to initiate therapeutic hyperthermia. She is assisted by Ryan Muhlenkamp, RN, (left) and Yonnie Demetiriades, RT.
It’s this reality that drove Gnan Thakore, MD, a specialist in internal medicine and critical care, to champion the use of therapeutic hypothermia at MVH. Dr. Thakore is also a clinical associate professor of medicine at Wright State University Boonshoft School of Medicine.
The roots of therapeutic hypothermia date back centuries when Greek physician Hippocrates advocated packing wounded soldiers in snow and ice. The method appeared in modern medicine in the 1950s, but wouldn’t become a part of standardized care until recently. In 2003, strong research led to its recommendation by the American Heart Association.
About that same time, Dr. Thakore began using forms of hypothermia with his patients while educating fellow physicians about its benefits.
It was clear that for optimal outcomes, therapeutic hypothermia would need to be initiated in the emergency department (ED). In 2009, informal talks turned serious when MVH made therapeutic hypothermia a top priority.
The hospital hired Andie Slivinski, RN, clinical nurse specialist for the ED, to evaluate current best practices. Slivinski helped make therapeutic hypothermia part of the hospital’s standard of care for cardiac arrest patients.
MVH invested in equipment and trained its medical staff on how the treatment worked. That way, therapeutic hypothermia can be started in the ED by one nurse, but continued by another in a different area of the hospital such as the Cath Lab.
Now, when medics bring in a cardiac arrest patient who has been successfully resuscitated, physicians and nurses are standing by, ready to start the hypothermia process. Still, hypothermia is not started on all cardiac arrest patients. They must fit certain criteria, including exhibiting signs of re-established cardiac and brain activity.
If the patient fits those criteria, therapeutic hypothermia is initiated with a cooling kit. The kit includes a head piece, a vest for the torso and arms and a blanket that is wrapped around the patient. Cold water is pumped through the various pieces to lower the patient’s body temperature gradually. The goal is to get the patient’s core body temperature down to 92 degrees Fahrenheit within six hours.
If that is done, then the patient’s chances of brain damage will drastically drop. Cooling a body’s temperature helps slow the metabolic processes including brain metabolism, but, more importantly, it diminishes the release of cellular substances that further damage brain cells.
Patients are sedated before the process begins and are given medication throughout the treatment to handle side effects such as shivering. About 24 hours later, patients are slowly warmed to a normal body temperature and then stabilized for any additional procedures they may have to undergo.
In Richard’s case, he would wait several days before undergoing open heart surgery, but he spent those days in good spirits visiting with family and even joking with medical staff.
More Success for Patients and Physicians
|Norman Schneiderman, MD
|Gnan Thakore, MD
|Ali Zaman, MD
Those who were at Richard’s side when he first came to the hospital are amazed at his recovery.
“He is one of the first [hypothermia] cases that I handled,” says Slivinski. “I saw him when he first came in. He had poor neurological signs, and the outcome looked ominous. But when I visited him in the heart and vascular intensive care unit a couple of days after his incident, he was sitting up in a chair talking with his family. My jaw dropped!”
Richard’s story supports a positive trend. Slivinski has kept close records of all MVH cases involving therapeutic hypothermia. Preliminary findings show it is changing patient outcomes. In 2010, the hospital observed an approximate fourfold improvement in the number of patients who were discharged post arrest with good neurological function.
“It used to be a very dismal statistic,” says Norman Schneiderman, MD, attending physician at MVH and clinical professor of emergency medicine at Boonshoft School of Medicine. “These new numbers are remarkable.”
Dr. Schneiderman says the ED’s goal is to continue to do as many hypothermia cases as it can, save more lives and increase its proficiency. His hope is that MVH’s Level I Trauma Center will become known as Southwest Ohio’s premier resuscitation center.
Meanwhile, therapeutic hypothermia is giving new purpose to heart surgeons like Ali Zaman, MD. Dr. Zaman, who is also a clinical assistant professor at WSU Boonshoft School of Medicine, says that while surgery can help save a patient’s life, it is sometimes useless after the brain has suffered such traumatic loss. Richard’s surgery was one of the first to prove to Dr. Zaman how critical therapeutic hypothermia is.
“Clearly without hypothermia, we would not have achieved the same kind of outcome,” says Dr. Zaman about Richard’s bypass surgery. “We can do a big operation to fix the heart, but if the brain is not working properly, then we can only achieve so much. In this case, we were able to fix the patient’s heart and give him back a normal life.”
Last Christmas, Richard visited Dr. Zaman to give him a bottle of wine in celebration of his recovery. Dr. Zaman still couldn’t believe how good he looked.
Richard’s incredible recovery is a testament to the wonders of modern medicine. Just a year earlier, he was wheeled into MVH with barely any sign of life. Today, he’s finding new ways to enjoy the second chance he’s been given.
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