Use of mild hypothermia after cardiac arrest - Book Report/Review Example

Paper Review Running Head: PAPER REVIEW Paper Review of a Dissertation and Study Format on the Use of MildHypothermia after Cardiac Arrest to Improve the Neurological Outcome Paper Review 2 Paper Review of a Dissertation The doctoral dissertation made by Robin Smith was about students with disability. It was a multiple case study type of qualitative research that also incorporated elements of grounded theory and content analysis. The author focused on 5 high school students Gerald, Trish, Nick, Tyrone and Abe who had significant intellectual disabilities. It examined the nature of the students' involvement in high school classrooms, as well as the teachers' perceptions and interpretations of the student's disabilities and academic performance.Sources of information were gathered from observations of the five students themselves who were enrolled in high school. The observations totalled 52 visits, for over 3 semesters, ranging in length from 15 minutes to 6 hours. The data gained from the different academic settings assisted in understanding the patterns of academic participations and the meanings and relationships of the 5 students regarding their academic participation in high school. Conversations and interviews were also sources of information. These were made with the general and special education teachers, assistants and parents - all concerned and involved with the students. The formal, informal and brief interviews were made during or in between class, after class, by appointment and through telephone - all according to the comfort level of the participants and their schedules. The discussions were about their educational goals for the students and / or how they thought the students were doing. For the parents, the following kinds of questions were asked : Paper Review 3 1. Tell me about the history of your child's schooling. 2. What are the child's strengths That is, what is he or she good at 3. Where does it get hard for the student 4. How does he or she like high school How can you tell 5. What do you see your child learning 6. What are your goals and dreams for your child 7. What else should I know about your child to better understand what is happening for him or her in school Official records and documents were another source of information. These were obtained from the district office of special education, which kept the official records of all 5 students. Each of the files contained the students' grades and the professional assessments and recommendations regarding the students' schooling. The author used the following tools to organize, code and analyze the collected data: audiotapes and transcriptions, a Hewlett Packard 200 LX - palmtop computer, a Q.S.R. Nudist, and the very detailed field notes. The audiotapes were used during the in-depth interviews of the participants to capture its details, as well as for reference and transcription. The palmtop computer enabled the author to take legible and detailed notes and add more detail soon after an observation. It was also used to facilitate data collection. The Q.S.R. Nudist was used to code data. It enabled the author to identify text segments in different ways that resulted in 98 data codes. Examples of the text segments were the participants' names and roles, and the assigned categories such as "engaged", Paper Review 4 "disengaged" and "academics". Categories were printed out in groups and coded them again by hand, testing new coding categories by merging several categories. The very detailed field notes were relied very heavily by the author. Included were the students' interactions with peers and adults, their reactions to what was going on, what the other students were doing at the same time, as well as the interactions of the non- speaking students. As data were collected and analyzed from preliminary observations, questions arose that needed further observing and interviewing. The author used the constant comparative method of analysis, looked for emerging themes and recurrent events, categorized them and reevaluated these themes and categories. As more data were collected, previous theories were reevaluated.The themes of academic engagement, generated by the author's pilot study, continued in extent and intensity, thus generating more themes that guided the study's development. As an example, one of the students observed was Nick who seemed an observer in class lectures and discussions, sitting in the last row with his assistant. The assistant supported him to participate in hands-on activities, but the assistant did the task for the student. His teachers commented that he doesn't understand much and that they did not expect him to benefit from the actual curriculum content. In contrast, a student with even less verbal expression and physical coordination, Trish followed a full academic schedule. Her teachers considered her to be interested, involved and learning. Thus, leading the author to look for signs of expectations of the student and how people evaluated them. Paper Review 5 In the course of the research, the author continuously examined her values and expectations as a continuing reminder of the role that values have in inquiry. As a disability rights advocate, she hoped that the research would be a contribution in achieving equality and full integration of people with disabilities. She expressed her prejudice against self-contained setting, where four of the students were based. To counter it, she remained cognizant of her bias in order to see what might actually benefit the students in that setting. She also expressed her prejudice against professional assessments. Fearing that early knowledge of the records might influence her interpretations of what she observed in the classroom, she countered it by waiting until the end of her study to read the assessments. She also took a class in how to administer psychoeducational assessments. The author was already learning less and less from observations by the end of spring. She eased her way out of the field gradually. Still keeping contacts with many of her informants to ask them how her students were doing. The first school year observation was completed, accelerated by the beginning of the university's summer session and the author's assignment in a suburban school as a student teacher. By the second summer and fall, she still had sessions with Trish and Tyrone, until the only thing lacking was the evaluation of the material from official records. The author waited until the following summer to look into the records, as she was able to find them a rich source of data. Paper Review 6 The Use of Mild Therapeutic Hypothermia after Cardiac Arrest To Improve the Neurologic Outcome: A Study Design Abstract Cardiac arrest with widespread ischemia frequently leads to severe neurologic impairment (Holzer, 2002). The study will enroll patients with asystole as the initial rhythym to assess whether mild therapeutic hypothermia will improve the neurologic outcome after resuscitation from cardiac arrest. Random selection of patients with asystole will either undergo therapeutic hypothermia for 24 hours or will receive a standard treatment with normothermia. The Use of Mild Therapeutic Hypothermia after Cardiac Arrest To Improve the Neurologic Outcome Out-of-hospital cardiac arrest is a leading cause of unexpected death in the developed world, occurring in about 1 in 1,500 adult each year ( Bernard, 2004 ). Recovery without residual neurologic damage after cardiac arrest with global cerebral ischemia is rare ( Holzer, 2002). Cardiac arrest, cardiorespiratory arrest, cardiopulmonary arrest is the abrupt cessation of normal circulation of the blood due to failure of the heart to contract effectively during systole. Prognosis after cardiac arrest is not favorable, with an overall survival rate of less than 6%. Cardiac arrest outcomes depend on the rhythym: less than 2% of patients with asystolic or pulseless electrical activity survive, comparing with 33% Paper Review 7 of patients with ventricular fibrillation or pulseless ventricular tachycardia. About 60% of cardiac arrest survivors regain consciousness; of these, one-third experience irreversible cognitive disabilities. Emergency life support focus on early aggressive resuscitation; but unfortunately, most patients who survive do sustain anoxic brain injury (Green, 2007). Anoxic brain injury happens when the brain severely lacks oxygen. The blood is unable to flow to the brain due to injury or bleeding. After cardiac arrest, free radicals and other mediators in the brain create chemical cascades resulting in brain injury. There are three phases of brain injury after hypoxic insult: early, intermediate and late (Howes, 2005). In the early stage, energy, glucose and oxygen are utilized due to the immediate decrease of blood flow in the brain. The intermediate phase is that level of brain injury wherein excitatory amino acids and other neurotoxic mediators are being released. This occurs hours post arrest.The late phase is when cerebral edema and blood-drain barrier are increased. Seizures and neuronal death may occur. This phase occurs up to 24 hours post arrest. Induced hypothermia (core temperature of 32 - 34 C) diminishes cell injury and increase cerebral neuronal healing by reducing cerebral oxygen demand and intracranial pressure, thereby suppressing the production and release of free radicals (Green, 2005). Studies have shown that cardiac arrest due to ventricular fibrillation (VF) has improved neurological outcome with the use of induced mild therapeutic hypothermia. Asystole or pulseless electrical activity, a dire form of cardiac arrest in which the heart stops beating, has not been sufficiently studied to recommend the routine use of hypothermic modulation of anoxic brain injury (Green, 2005). Until recently, prognosis of patients with asystolic out-of-hospital cardiac arrest have not been encouraging due to lack of Paper Review 8 clinical data. The research will be a multiple case study that will include content analysis and grounded theory research. Comparative and statistical analysis in data will also be applied. The study design is constructed to ensure construct validity, internal validity, external validity and reliability so that confidence in the findings will be established. Patients are the unit of analysis (individuals). Methods The site is a hospital setting using multiple investigators, the researcher being the chief investigator. The study will be a randomized, controlled trial wherein patients with asystole will be randomly selected to either undergo therapeutic hypothermia for 24 hours or receive a standard treatment with normothermia. Treatment and observation will be up to 2 years upon admission. The following are the patient criteria for admission: a witnessed cardiac arrest, asystolic or pulseless electrical activity as the initial rhythm with a return of spontaneous circulation (ROSC), ages 18-75 male or female, and unconscious upon admission. Approved protocol and consent procedure by the institutional review board (IRB) will be made and obtained. The Institutional Review Board, also known as the Independent Ethics Committee (IEC) or the Ethical Review Board is the regulatory body responsible for the review of the research that involves human participants. Its aim is to protect the rights and welfare of the research subjects. They are empowered by the government to approve, disapprove or require modifications in research. The patients' Paper Review 9 family will be informed about the trial and that if there will be objections, the patient/s will be withdrawn from the trial. The patient participation in the study is voluntary and he/she is entitled to be free from undue embarrassment, discomfort, anxiety and/or harassment.To ensure anonymity and confidentiality for the participants, the principal investigator/sponsor has/have the obligation to protect patient information - such information shall not be communicated to others unless the following circumstances are met: 1. Explicit written permission for the release of identifying data is given by the individual. The consent form to release information is separate or independent from the informed consent. 2. Information about the individual must be discussed for professional purposes only. Every effort should be made to avoid invasion of privacy. 3. Provisions must be made to maintain confidentiality in the preservation and ultimate disposal of any collected data. Adequate security measures must be implemented until the records are destroyed. Personal information contained in the records that could allow another person to identify a subject should be destroyed in keeping with the federal regulations requiring maintenance of data for 3 years (Institutional Review Board for the Protection of Human Subjects, 2007). All patients will be sedated and will receive standard care. Sedation will be induced by intravenous administration of medazolam and fentanyl ( Holzer, 2002). Shivering during Paper Review 10 cooling leads to warming and will increase overall consumption, thus make cooling more difficult. To counter it, neuromuscular blocker pancuronium will be induced by intravenous administration ( Holzer, 2002). For the hypothermia group ice packs to the groin, axillae, and neck and the use of a cooling mattress with cover will be used in order to attain a target core temperature of 32 - 34 C (Holzer, 2002; Howes, 2005). The 32 - 34 C temperature will be maintained for 24 hours from the onset of cooling, after which, passive rewarming at 36 C will be applied for 8 hours as rebound hyperthermia may occur. Then active rewarming with forced air warming to normothermia will follow. Continuous and frequent temperature measurements will be taken by bladder with the use of a bladder-temperature probe. For the normothermia group, normothermia at 37 C will be maintained while patients are placed in a conventional bed with the standard ICU care. One phase in the methodology is the clinical/medical interview to be conducted with each of the patients' family members. The clinical interview is a special kind of professional interview in which the purpose is to increase understanding of the person's illness. This is done upon admission of the patient to the hospital and during the course of treatment. Questions asked are in regards the chief complaint before the cardiac arrest, the history of present illness, past medical history, family history and the patient being enrolled in the clinical trial. Examples of these questions are: what did the patient complained about before the cardiac arrest Tell me how the incident happened What time did the incident occur Did the incident occurred before What were the Paper Review 11 circumstances Who was/were with the patient during the incident How do you feel about the patient being enrolled in the clinical trial Patient profile, review of systems and consent document are also discussed and asked. The clinical interview will be prepared by reviewing the patient's chart, assessing and preparing the physical environment by making sure that the comfort and privacy of the interview are optimized, as well as minimizing destructions and interruptions so that a relaxed environment is set in order to obtain a detailed information from the family members. Rapport/relationship building must also be established so that a basis for trust is obtained. Open-ended questions will be used so that holistic understanding and evaluation of the situation is obtained. Staff members are also interviewed to provide depth of detail and evaluation. The interview will be conducted in the hospital such as the patient's room for the family members. Data Collection and Analysis Protocols on baseline characteristics, details on cardiac arrest, out-of-hospital procedures and events, cooling and rewarming procedures, neurological and functional outcome scores at discharge, information on possible adverse events and death will all be documented. The Utstein style will be used to record data on cardiac arrest for individual patients. The Utstein style is a standardized guideline / format for publication of academic articles in emergency medicine. It outlines what type of data should be reported. A collection of the recommended variables will enable intrahospital and interhospital comparisons and support national and internationalresearch. The Paper Review 12 neurological status is monitored with the use of the Glasgow Outcome Scale, an assessment measurement of outcome after severe brain damage. The Pittsburgh Cerebral Score will measure the neurologic outcome. The scales developed primarily to facilitate the assessment and recording of initial severity of brain dysfunction. Its aim is to use simple terms that could be easily understood by a wide range of observers including doctors, nurses and others. A complete statistical software package for managing, graphing and analyzing data, the stata 10 will also be utilized. Paper Review 13 References Arrich J. (2005). Clinical application of mild therapeutic hypothermia after cardiac arrest. Critical Care, 9: 297. Bernard, S. (2004). Therapeutic hypothermia after cardiac arrest. The Medical Journal of Australia, 181: 468-469. Green, R. & Howes W. (2007). Stock your emergency department with ice packs: a practical guide to therapeutic hypothermia for survivors of cardiac arrest. Canadian Medical Association Journal, 176: 759-762. Holzer, M. (2002). Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. New England Journal of Medicine, 346: 549-556. Howes, D. (2005). Position statement and guidelines for the use of hypothermia after cardiac arrest. Canadian Association of Emergency Physicians, C4. Indiana University of Pennsylvania. (2007). Institutional Review Board for the Protection of Human Subjects. . Read More