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18 - Problems and Pitfalls of Qualification for Extracorporeal Treatment of Patients in Severe Hypothermia
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- By Anna Jarosz, “Heat for Life” Foundation, Cracow, Poland, Sylweriusz Kosiński, Department of Anesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland, Tomasz Darocha, “Heat for Life” Foundation, Cracow, Poland, Hubert Hymczak, Tatra Mountain Rescue Service, Zakopane, Poland, Peter Paal, Head of the Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brother Hospital, Salzburg, Austria, Rafał Drwiła, Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Cracow, Poland
- Edited by Sylweriusz Kosiński, Tomasz Darocha, Jerzy Sadowski, Rafał Drwiła
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- Book:
- Hypothermia: Clinical Aspects Of Body Cooling
- Published by:
- Jagiellonian University Press
- Published online:
- 03 January 2018
- Print publication:
- 01 December 2016, pp 161-168
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Summary
If indications for extracorporeal rewarming in hypothermia are clearly defined, the problems one might encounter in practice have not been, as yet, delineated. Isolated reports on “qualification pitfalls” appear in certain case studies, but majority of these constitute only relative contraindications. In patients with instability of cardiovascular system, and cardiac arrest in particular, decision to qualify for extracorporeal rewarming must be immediate. At the same time, diagnostic possibilities are significantly limited (incoming reports from emergency medical teams or mountain rescue services, patients undergoing resuscitation or extremely unstable). In such instances not qualification, but denial of extracorporeal treatment may present the greatest challenge on both clinical as well as ethical planes.
The compilation of problems and pitfalls experienced during qualification procedure is based upon several months of work of Severe Hypothermia Treatment Centre coordinators in Kraków. It is until now the only centre specialising in extracorporeal rewarming in Poland, and the only one operating according to proprietary, uniform algorithm. This has allowed to observe recurrence of certain conditions, assess their importance and draw appropriate conclusions. ECMO therapy carries a risk of grave complications, but majority of these can be avoided by means of proper qualification procedure and avoidance of factors which affect the very treatment. As emphasised before, the problems described below constitute merely relative contraindications, and thanks to good long term outcomes of extracorporeal rewarming, they should be considered in relation to a complete disorder evaluation and discussed by the team involved in the treatment.
Thrombocytopenia and/or clinically important anaemia
These disorders are present in patients belonging to so called “underclass”, but also in the elderly, neglected and malnutrition stricken victims of “urban hypothermia.” The values of haemoglobin seen in our patients reached even 3.6 mg/dL and thrombocyte count 18,000/mL. It should be stressed that even such low parameters do not constitute a contraindication for extracorporeal rewarming, yet require intervention.
14 - Coagulopathies in Hypothermic Patient
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- By Hubert Hymczak, Severe Hypothermia Treatment Centre, Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Cracow, Poland, Mirosław Ziętkiewicz, Department of Anaesthesiology and Pulmonary Intensive Care, John Paul II Hospital, Cracow, Poland, Dariusz Plicner, The Department of Cardiovascular Surgery and Transplantation, John Paul II Hospital, Cracow, Poland
- Edited by Sylweriusz Kosiński, Tomasz Darocha, Jerzy Sadowski, Rafał Drwiła
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- Book:
- Hypothermia: Clinical Aspects Of Body Cooling
- Published by:
- Jagiellonian University Press
- Published online:
- 03 January 2018
- Print publication:
- 01 December 2016, pp 131-138
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Summary
Pathophysiology
Haemostasis is a group of complex and inter-related processes maintaining integrity of blood vessels both in normal conditions as well as after vessel damage. The role of haemostasis in case of vessel wall damage is formation of clot, followed by fibrinolysis and restoration of normal flow.
Proper functioning of haemostasis is enabled by plasma components, mainly platelets, blood vessel wall (vascular endothelium), as well as coagulation and fibrinolysis systems. In normal conditions, balance between coagulation and fibrinolysis systems is maintained.
Coagulation system, particularly in its plasmatic aspect, is a series of enzymatic reactions vitally dependent on temperature and pH. The optimal functioning of the system coincides with physiological body temperature, hence drop in body temperature entails significant disturbances in the process.
Coagulopathy in hypothermia is a result of decrease in activity number of platelets, reduction in activity of plasma coagulation factors, and enzymatic processes [1–3]. Relationship between drop in blood temperature and occurrence of coagulopathy, however, is not linear. It is accepted that decrease of 1oC of body temperature causes decrease of function of coagulation system by 10%.
Hypothermia in the range 37–33°C causes mainly platelets adhesion disorders without disturbing significantly neither their activation nor enzymatic activity of plasma factors [1–4]. Furthermore, an increased sensitivity of blood platelets to pro-coagulation factors is observed, what translates into increased capacity to form clots in peripheral parts of the body, more exposed to potential injury [4]. Only in temperature lower than 33°C significant haemostasis disorders are observed, related mainly to reduced activity of thrombocytes and enzymatic activity [1, 2, 5].
Paradoxically, in chronic hypothermia (with polyuria and dehydration) haemoconcentration with increase of hematocrit by 2% for each °C < 34°C may occur [6, 7], as well as vasoconstriction, release of tissue thromboplastins, and increase in fibrinogen concentration. These may lead to clotting and occurrence of embolism.
19 - Procedure of Extracorporeal Treatment of Hypothermic Patients
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- By Tomasz Darocha, “Heat for Life” Foundation, Cracow, Poland, Sylweriusz Kosiński, Department of Anesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland, Anna Jarosz, “Heat for Life” Foundation, Cracow, Poland, Hubert Hymczak, Severe Hypothermia Treatment Centre, Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Cracow, Poland, Robert Gałązkowski, Department of Emergency Medical Services, Medical University, Warsaw, Poland, Tomasz Sanak, Department of Disaster Medicine and Emergency Care, Chair of Anaesthesiology and Intensive Care, Jagiellonian University Collegium Medicum, Cracow, Poland, Jerzy Sadowski, The Department of Cardiovascular Surgery and Transplantation, Jagiellonian University Collegium Medicum, John Paul II Hospital, Cracow, Poland, Bogusław Kapelak, The Department of Cardiovascular Surgery and Transplantation, Jagiellonian University Collegium Medicum, John Paul II Hospital, Cracow, Poland, Rafał Drwiła, Department of Anaesthesiology and Intensive Care, John Paul II Hospital, Cracow, Poland
- Edited by Sylweriusz Kosiński, Tomasz Darocha, Jerzy Sadowski, Rafał Drwiła
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- Book:
- Hypothermia: Clinical Aspects Of Body Cooling
- Published by:
- Jagiellonian University Press
- Published online:
- 03 January 2018
- Print publication:
- 01 December 2016, pp 169-176
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- Chapter
- Export citation
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Summary
In June 2013 the first Polish system of qualification for extracorporeal rewarming of patients in severe hypothermia was developed, it encompasses with its reach the patients of Lesser Poland Voivodeship. The core of the system is Severe Hypothermia Treatment Centre (SHTC) by Department of Anaesthesiology and Intensive Care at John Paul II Hospital in Kraków. Its objective is treatment of severe stages of hypothermia with extracorporeal membrane oxygenation (ECMO) method as well support of cooperating entities with knowledge and aiding them in decision making process. The concept of the entire programme and procedure itself were based upon experts’ recommendations as well as experience of other centres in the world [1–3], but reach and range of activity of SHTC are exceptional.
The idea of the system development was based on previous experience of the systems originators and information gathered via countrywide questionnaire concerning hypothermia diagnosis and treatment [4]. Hypothermia, and its severe stages in particular, is diagnosed sporadically, but its incidence rate is probably higher than implied by the official statistical data. The means of treatment which were put to use have not always been successful, and instances of extracorporeal techniques were merely anecdotal. We assumed that the only way of increasing the efficacy of treatment is developing a system which will provide full care of the patients – from early identification, through safe transportation, up to present-day and efficient possibilities of rewarming and life support. Initially the victims of acute exposure hypothermia (e.g. in the mountains, after cold water immersion) were in the scope of our interest, but, according to our expectations, chronic urban hypothermia has proven to be the greatest challenge.
The system would fail to function without broad educational and information campaign. Series of trainings for physicians, nurses, paramedics and also for the police, fire departments, and other entities cooperating with the system was initiated. During the meetings the means of recognising and treatment of hypothermia were discussed, population at risk was identified, and newly developed algorithm was presented. Educational materials and information on methods of notifying system coordinator reached all emergency departments (20 emergency departments proper and 11 inpatient departments), ambulance stations, fire departments, railroad police units, employees of 6 national parks, border guard, and police departments within the voivodeship.
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