Use of a standardized order set for achieving target temperature in the implementation of therapeutic hypothermia after cardiac arrest: a feasibility study.

OBJECTIVES: Induced hypothermia (HT) after cardiac arrest improved outcomes in randomized trials. Current post-cardiac arrest treatment guidelines advocate HT; however, utilization in practice remains low. One reported barrier to adoption is clinician concern over potential technical difficulty of HT. We hypothesized that using a standardized order set, clinicians could achieve HT target temperature in routine practice with equal or better efficiency than that observed in randomized trials. METHODS: After a multidisciplinary HT education program, we implemented a standardized order set for HT induction and maintenance including sedation and paralysis, intravenous cold saline infusion, and an external cooling apparatus, with a target temperature range of 33-34 degrees C. We performed a retrospective analysis of a prospectively compiled and maintained registry of cardiac arrest patients with HT attempted (intent-to-treat) over the first year of implementation. The primary outcome measures were defined a priori by extrapolating treatment arm data from the largest and most efficacious randomized trial: 1) successful achievement of target temperature for >or=85% of patients in the cohort and 2) median time from return of spontaneous circulation (ROSC) to achieving target temperature <8 hours. RESULTS: Clinicians attempted HT on 23 post-cardiac arrest patients (arrest location: 78% out-of-hospital, 22% in-hospital; initial rhythm: 26% ventricular fibrillation/tachycardia, 70% pulseless electrical activity or asystole) and achieved the target temperature in 22/23 (96%) cases. Median time from ROSC to target temperature was 4.4 (interquartile range 2.8-7.2) hours. Complication rates were low. CONCLUSIONS: Using a standardized order set, clinicians can achieve HT target temperature in routine practice.

Packed red blood cell transfusion in the intensive care unit: limitations and consequences.

OBJECTIVE: To review the literature on the limitations and consequences of packed red blood cell transfusions, with particular attention to critically ill patients. METHODS: The PubMed database of the National Library of Medicine was searched to find published articles on the indications, clinical utility, limitations, and consequences of red blood cell transfusion, especially in critically ill patients. RESULTS: Several dozen papers were reviewed, including case series, meta-analyses, and retrospective and prospective studies evaluating the physiological effects, clinical efficacy, and consequences and complications of transfusion of packed red blood cells. Most available data indicate that packed red blood cells have a very limited ability to augment oxygen delivery to tissues. In addition, the overwhelming preponderance of data accumulated in the past decade indicate that patients receiving such transfusions have significantly poorer outcomes than do patients not receiving such transfusions, as measured by a variety of parameters including, but not limited to, death and infection. CONCLUSIONS: According to the available data, transfusion of packed red blood cells should be reserved only for situations in which clear physiological indicators for transfusion are present.