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Adjusting the human thermostat

UPMC clinicians perfect cooling, warming techniques to optimize patient care

Iced-down fluids are given intravenously to a patient who experiences cardiac arrest. In the Emergency Department, the cooling continues by placing the man on a spongy blanket through which near-freezing water circulates.

In another clinical setting, a radically different set of body temperature strategies is used to keep a patient undergoing a surgical procedure as warm as possible. On the day of surgery, the patient pulls on extra clothing and travels to the hospital in a prewarmed car. In the Operating Room, the upper torso of the patient is surrounded with a blanket into which warm air is forced.

UPMC clinicians are designing evidence-based methods to cool or warm core body temperatures to meet a variety of clinical needs. The results speak for themselves. Using cooling techniques, UPMC providers have improved the likelihood that patients will resume productive lives after sudden, abrupt loss of heart function. By maintaining normal body temperatures during surgery, UPMC physicians and nurses are helping to ensure that patients return home as soon as possible.

Chilling out to protect the brain

On a snowy January morning, Jon Rittenberger, MD, begins his day in the Emergency Department at UPMC Presbyterian by explaining how UPMC is using therapeutic hypothermia (TH) to save lives and improve outcomes for patients who have suffered a cardiac arrest.

The goal of the TH protocol is to lower the core temperature of comatose survivors of cardiac arrest to 91 degrees Fahrenheit (98.6 degrees Fahrenheit is considered normal) for a 24-hour period after resuscitation.

The cooling decreases the metabolic needs of the brain. “We are protecting the brain because it needs less oxygen and nutrients to survive, which increases the likelihood of a favorable neurologic recovery,” says Dr. Rittenberger, assistant professor, Department of Emergency Medicine.

In an article published last fall in the journal Resuscitation, Dr. Rittenberger and his colleagues concluded that patients who experienced out-of-hospital cardiac arrests and then underwent TH interventions used at UPMC were six times more likely to survive and return to their homes after recovery.

“It’s no longer acceptable just to survive a cardiac arrest. The goal is to get these patients back to their jobs, their families, back to enjoying productive lives, which is eminently satisfying for everyone I work with,” says Dr. Rittenberger, one of UPMC’s three on-call specialists available 24/7 to oversee TH and other aspects of postresuscitation care. The other specialists are Clifton Callaway, MD, and Francis Guyette, MD.

These UPMC experts and others regularly meet with STAT MedEvac, Pittsburgh’s Bureau of Emergency Medical Services, and ambulance crews in suburban areas to stress the importance of keeping chilled saline or other intravenous solution in stock and to administer it to cardiac arrest patients before they arrive in the ED.

Other initiatives have increased the use of TH at UPMC Presbyterian and UPMC Shadyside and have set the stage for expanded implementation at other UPMC hospitals. A standardized order set ensures TH is delivered consistently using protocols supported by evidence-based medicine. TH kits with necessary supplies to cool patients properly and maintain lowered body temperature have been stocked in EDs and intensive care units so they can be accessed immediately.

Warming up to prevent surgical complications

While those treating patients with cardiac arrest strive to cool body temperatures, UPMC clinicians in preoperative, surgical, and postoperative settings work to keep their patients as warm as possible.

“Body temperature drops rapidly following the induction of general anesthesia. For most surgery patients, this decline increases the risk for unintended hypothermia — a potentially dangerous complication associated with higher mortality rates, longer hospital stays, and an increased rate of wound infection,” explains Joseph Quinlan, MD.

To address such concerns, the chief anesthesiologist at UPMC Presbyterian serves on a multidisciplinary team charged with keeping surgical patients at a normal body temperature before, during, and after surgery.

The emphasis on maintaining body warmth starts even before the patient leaves home for the hospital. “We tell our patients to turn up the heater before they get into the car for the ride to the hospital,” explains Dr. Quinlan.

Maintaining normal body temperature during surgery is linked to the goals of the Surgical Care Improvement Project (SCIP), a national quality partnership of organizations com­mitted to improving the safety of surgical care through the reduction of postoperative complications.
SCIP currently requires that patients undergoing colorectal procedures attain normal body temperature within 15 minutes of leaving the OR. “We anticipate that standard will be expanded to all surgical patients,” says Steven Hughes, MD, chairman of UPMC Presbyterian’s Surgical Services Oversight Committee.

Drs. Hughes and Quinlan note that a range of steps are being taken to keep ORs and other areas for surgical patients as warm as possible. For example, OR temperatures will be maintained at a minimum temperature of 72 degrees Fahrenheit. Pads with warm circulating water, blankets filled with warm air to surround large sections of the body, equipment to keep intravenous fluids and blankets warm prior to use, and protocols to cover exposed skin intraoperatively are some of the tools at their disposal.

Other considerations must be taken into account as well. Working under intense OR lights while wearing necessary sterile clothing and equipment can be difficult for the surgical team. “That’s why we will evaluate new technology such as a water-cooled vest that surgeons and other OR staff may wear to keep comfortable,” says Dr. Hughes.