HYPOTHERMIA / NORMOTHERMIA: ARCTIC SUN TEMPERATURE MANAGEMENT SYSTEM PROTOCOL AND PROCEDURE

of 7 TOPIC: MANAGEMENT SYSTEM PROTOCOL AND PROCEDURE PURPOSE: To outline the nursing management of a patient receiving hypothermia or normothermia therapy via Arctic Sun Temperature Management System APPLICABILITY: Intensive Care Units SUPPORTIVE DATA: 1. Fever is defined as body temperature greater then 38.3 degrees Celsius. Fever is known to increase secondary brain injury, worsen functional outcome, and increase mortality rate in neurologically injured patients. In addition, fever is directly associated with longer ICU and hospital length of stay. Neurologically injured patients, specifically patients with subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), traumatic brain injury (TBI) and new-onset stroke are 25-50% more at risk for developing fever. 3. Hypothermia is defined at body temperature less then 35.0 degrees Celsius. Normothermia is defined as body temperature 35.0 degrees Celsius to 38.3 degrees Celsius. 4. Hypothermia has been shown to decrease intracranial pressure (ICP) in patients with severe head injuries and should be considered when all medical and surgical treatments have been explored. Hypothermia may also be initiated following large ischemic stroke, status epilepticus, encephalitis, acute MI, status post cardiac arrest or as otherwise indicated by an ICU attending. 5. The Arctic Sun Temperature Management System provides rapid, noninvasive temperature management through surface cooling via Energy Transfer Pads. The combination of the Arctic Sun Control Module and Energy Transfer Pads were designed to cool a patient by simulating water immersion. The three-layered pads consist of an outer layer of insulated foam, a middle layer of rapid water circulation, and a bottom hydrogel layer which allows for safe skin application. Core body temperature is monitored via urinary bladder thermistor.

of 7 6. Contraindications: Arctic Sun hyperthermia/normothermia therapy is contraindicated in patients who: a) Are diagnosed with vasodilatory shock and who require treatment with multiple vasoactive agents. Arctic Sun therapy may increase risk for thermal skin injury. b) Have generalized dermatological illness. Avoid pad placement over skin which is excoriated, inflamed, or denuded. ADMINISTRATION/PROCEDURE: 1. The Arctic Sun Temperature Management System may be administered by critical care nurses trained in the use of the system. 2. Review indication for Arctic Sun therapy (see above contraindications): a. Patient has two documented temperature measurements greater than 38.3 degrees C despite Acetaminophen and/or Ibuprofen administration. b. Patient does not have any contraindications to Arctic Sun therapy (see contraindications listed below). 3. As per physician/np/pa written order, pre-medicate patient with Buspirone Meperidine at least 30 minutes prior to initiation of Arctic Sun therapy. Buspar is generally ordered as standing medication. 4. Gather Arctic Sun equipment a. Arctic Sun Control Module, b. Arctic Sun Energy Transfer Pads (pads), c. Gloves, d. Sterile Water, and e. Bard temperature sensing foley catheter. 5. Place Bard temperature sensing foley catheter per NYPH policy. 6. Place pads on patient. Remove any creams or lotions from patient s skin prior to pad placement. Pads are packaged in three sizes. Size is based on patient s body height and weigh (sizing chart is located on energy transfer pad packaging). Place all four pads, two on upper body and one on each thigh, as depicted on label located on each pad. Universal pads can be added to a basic set for patients weighting more than 100 kg. 7. Attach fluid delivery line from module to each pad. 8. Turn module power on (located on back of module).

of 7 9. If water level is empty, follow prompts. Fill with sterile water using fill in tube (located on back of module). 10. Set the ordered patient target temperature using the up and down arrow keys. 11. Set mode to Automatic Mode. 12. Connect Foley thermistor to Arctic Sun. Monitor will display patient s temperature. 13. Begin cooling by activating Automatic Mode. 14. Review physician/np/pa orders. Physician/NP/PA must order hypothermia/normothermia therapy. Order must state desired patient target temperature. 15. Monitor for shivering (see below). NURSING ASSESSMENT AND CARE: A. Assessment 1. Perform neurological assessment of the patient, including but not limited to, level of consciousness, cranial nerve deficits motor strength and tone every hour or as ordered. 2. Assess vital signs including HR, cardiac rhythm, BP, RR, SaO 2, and ICP every hour, prn, or as ordered. Anticipate bradycardia, hypotension, decreased respiratory rate, and arrhythmias as potential side effect of hypothermia therapy. 3. Assess core body temperature during hypothermia/normothermia therapy every hour. 4. Assess skin integrity, including skin located under pads. Notify MD/NP/PA immediately of any new skin breakdown, rash, or excoriation. 5. Assess for shivering. a) Shivering is usually first noted by artifact in ECG tracing. Also assess for shivering by palpating massetter muscle for humming vibration and by observing skeletal muscle movements commonly seen in the deltoids and pectoralis muscles. b) Notify physician/np/pa of shivering. c) Place Bair Hugger blanket as first treatment for shivering. Set Bair Hugger machine to maximum setting (42.0 degrees C). Cover top of patient s head with warm blanket. Place socks on feet. d) Administer Acetaminophen as ordered.

of 7 e) Anticipate prn Meperidine. Avoid overmedication which may cloud neurological exam and/or cause hypotension. Meperidine should not be administered in patients with on-going seizures, renal insufficiency, or MAOI use within the past 14 days. f) If shivering persists despite Bair Hugger and Meperidine administration, anticipate the following medications to be started: a. Magnesium Sulfate IV continuous infusion per physician/np/pa order. Monitor serum magnesium every 4 hours. Magnesium goal is 2-4mg/dL) b. Dexmedetimidine continuous infusion per physician/np/pa order. Monitor for over sedation. May be administered in non-intubated patient. c. Cisatracuriam continuous infusion for refractory shivering. per physician/np/pa order. Patient must be intubated prior to administration. Goal 1-2/4 TOF. Refer to neuromuscular administration protocol. B. Ongoing assessment and care 1 Transporting patient: Therapy must be stopped for transporting patient. ARCTIC SUN PADS ARE MRI COMPATIBLE. Do the following steps to pause Arctic Sun therapy. a) Press STOP key. b) Press PURGE key. c) Disconnect fluid delivery lines when purging is complete. d) Disconnect Foley thermistor. e) Transport patient per NYPH protocol. f) To continue therapy when patient returns to unit, re-connect fluid delivery lines to pads, reconnect Foley thermistor, and press START. 2. Pad life: Arctic Sun pads are effective for 72 hours. Replace pads every 72 hours or as needed. 3. Temperature monitoring: The Arctic Sun Module is able to determine whether a patient is actively spiking a temperature during normothermia therapy. A patient is considered to be actively spiking when water temperature is less than 10 degrees C.

of 7 6. Rewarming following hypothermia: Rewarming a patient to normothermia following hypothermia therapy is a slow process. Rewarming must occur over no less than 12 hours. To rewarm: a) Press the down arrow once until warm-max automatic mode is displayed, b) Press enter to change displayed value c) Hold down arrow until desired rewarming temperature is displayed d) Press enter to save e) Press automatic mode to begin rewarming 4. Troubleshooting: Troubleshooting if the target temperature has not been reached in 3 hours: a) Evaluate patient for shivering. Treat with prn medications. b) Examine Arctic Sun pads. Ensure that a. The device is in Automatic Mode b. There are at least four pads on the patient c. Fluid delivery lines are connecting and flowing appropriately. Make certain that the pad flow rate is >2.3 liters per minute. Flow rate can be found on Module. d. The water temperature is below 10 degrees C if the patient is greater than 1 degree C above target temperature. 5. Suspending therapy: Therapy may be suspending when Arctic Sun water temperature reads greater than 30 degrees C for at least 24 hrs. Physician/NP/PA must D/C Arctic Sun orders including prn medications. PATIENT/FAMILY EDUCATION: 1. Instruct the patient/family regarding the need for hypothermia/ normothermia therapy. 2. Educate the patient/family of adverse effects of therapy (i.e. shivering, bradycardia, decreased respiratory rate, hypotension, arrhythmias, cold or pale skin) 3. Educate the patient/family of additional treatments and medication regiment to prevent shivering.

of 7 DOCUMENTATION: 1. Patient s neurological status. 2. Vital signs every 1 hour and prn. 3. Core body temperature every hour. 4. Arctic Sun water temperature every hour. 5. Ordered target temperature. 6. Bair Hugger use and set temperature if used. 7. Shivering, treatment administered to prevent/stop shivering, and patient s response to treatment. Patient and family teaching and understanding. REFERENCES: Marion, D.W. (2004). Controlled normothermia in neurological intensive care. Critical Care Medicine, 32(2 Suppl) S43-5. Diringer, M.N., Reaven, N.L., Funk, S.E., Uman, G.C. (2004). Elevated body temperature independently contributes to increased length of stay in neurological intensive care unit patients. Critical Care Medicine. 32(7) 1489-95. Mayer, S.A., Sessler, D. I. Therapeutic Hypothermia. New York: Marcel-Dekker, 2005. www.medivance.com (2007). RESPONSIBILITY: Critical Care KEY WORDS: Hypothermia, Normothermia, Arctic Sun Temperature Management System, neuro, neurological, critical care, fever, shivering

of 7 APPROVAL METHOD: Department Approver s Name Title Signature Date Nursing Wilhelmina Manzano, MA, RN, CNAA, BC Senior Vice President and CNO Signature Copy On File 8/07 Committee Date approved by Committee Nursing Practice Council 7/07