Cardiovascular Critical Care II

Endocrinologic

Endocrinology 1970;87:750-5)

Hyperglycemia caused by decreased insulin production and effect in

periphery, increased gluconeogenesis, and glycogenolysis

Continuous insulin infusions may be necessary for glucose control. Goal

should be < 180 mg/dL without inducing hypoglycemia

Renal

Neurosurg 2001;94:697-705)

Decreased effective glomerular filtration (urine output may increase

because of cold diuresis, but not effective clearance)

Electrolyte shifts (K+, PO43-, Na+, Ca2+) during cooling phase; reverse

upon rewarming, thus caution should be exerted with replacement

Hematologic

Br J Haematol 1999;104:64-8;

Coagulopathy caused by thrombocytopenia, impaired activation and

activity of clotting factors, impaired platelet function

Actively bleeding patients should not be cooled

Fentanyl

Plasma concentration increases by 25% with a 3.7-fold decrease in clearance

Morphine

Receptor affinity (µ) decreases as temperature decreases

Propofol

Plasma concentration increases by 28%; decreased clearance

Midazolam

Clearance decreases by about 11% per degree below 36.5°C

Rocuronium

Clearance decreases by 50%, increases duration of action 2-fold

Vecuronium

Clearance decreases by 11% per degree Celsius; increases duration of action 2-fold

Cisatracurium

Eliminated by Hofmann elimination, which is a temperature-dependent enzymatic process;

anticipate prolonged activity

Phenytoin

AUC (area under the concentration-time curve) increases by 180%; clearance and elimination

rate constant decrease by 50%

Anaesthesiol Suppl 1995;1:95-106; Clin Pharmacol Ther 1979;25:1-7)

vi.

Rewarming should be a passive process (around 0.33°C–0.5°C per hour) (Acta Anaesthesiol

Scand 2009;53:926-34; N Engl J Med 2002;346:557-63; N Engl J Med 2002;346:549-56).

Rapid rewarming can cause extreme electrolyte shifts and vasodilation with associated

hypotension.

vii.

Though the exact temperature goals and duration of temperature control is still being

investigated, avoidance of fever and hyperthermia is clear and should be maintained during

the first 48–72 hours after cardiac arrest (Arch Intern Med 2001;161:2007-12; Resuscitation

Identify and treat acute coronary syndromes.

Cardiovascular disease and acute coronary ischemia are the most common causes of cardiac

arrest (Am Heart J 2009;157:312-8; N Engl J Med 1997;336:1629-33).

ii.

Consideration of treatment of acute coronary syndromes should not be deferred in patients who

are comatose or when temperature control is used.