Anesthesia and Analgesia Protocol During Therapeutic Hypothermia After Cardiac Arrest

Abstract

There is great variability in the protocols used for anesthesia and analgesia during therapeutic hypothermia. Very often, the drug and the dose used do not seem the most appropriate. Only 3 ICUs routinely used electroencephalographic monitoring during paralysis. It is necessary to reach a consensus on how to treat this critical care population.

Optimal Management of Shivering During Therapeutic Hypothermia After Cardiac Arrest

“…Chamorro et al 26 found that fentanyl and morphine, in that order, were the most common analgesics used during therapeutic hypothermia after cardiac arrest. Both drugs effectively reduce shivering and cause moderate sedation; however, morphine has a greater risk of causing hypotension.…”

“…Common sedatives used during therapeutic hypothermia to reduce the shivering threshold include propofol, dexmedetomidine, midazolam, and diazepam. Chamorro et al 26 conducted a systematic literature review and found that midazolam and propofol, in that order, were the sedative agents used most often. Doses of 2.5 to 10 mg of midazolam are moderately effective in reducing shivering, although the drug also has a high sedative effect and a low risk of hypotension.…”

“…When shivering occurs regardless of optimal sedation, many therapeutic hypothermia protocols recommend use of a paralytic agent (ie, a neuromuscular blocker) to control shivering. 3 Chamorro et al 26 found that pancuronium was the most common paralytic agent used during therapeutic hypothermia after cardiac arrest. However, in a study by Dupuis et al, 28 vecuronium was preferred over pancuronium for reduction of shivering because the former did not increase myocardial work and was associated with fewer complications.…”

Postcardiac Arrest Management

“…98 Hypothermia decreases metabolism and excretion of midazolam in healthy individuals. 99 In addition, renal impairment is commonly encountered during the postarrest phase.…”

Therapeutic Hypothermia for Acute Neurological Injuries

“…However, caution is warranted during TH because peripheral nerve conduction is significantly slowed by cooling, and trainof-four testing may not be a reliable monitoring method at low body temperatures [70].…”