Therapeutic Hypothermia Post Cardiac Arrest - Essay Example

School: THERAPUTIC HYPOTHERMIA POST CARDIAC ARREST Lecturer: THERAPUTIC HYPOTHERMIA POST CARDIAC ARREST Introduction In the delivery of roles as nurses, there are several skills, competences and knowledge that must come to play. Sehati (2009) noted that the levels of these skills, competence and knowledge are very crucial for ensuring successful delivery of service as professional nurses. However, a nurse would really not have a sense of advancement in the execution of these skills, competence and knowledge if there are not concrete methodologies with which the duties they carry out are adequately measured. In this, Arcure and Harrison (2009) noted several means by which nurses can adequately measure their levels of output in relation to the application of basic and advanced skills, competence and knowledge. One of these means is identified to include the use of reflective analysis, whereby after any major task with a patient, the nurse sits back to reflect on the nursing practice that was executed, using a series of methodologies and procedures. In this paper, such clinical judgment in the nursing management of a patient is undertaken. The patient was taken care of after post cardiac arrest during the first 6 hours of his initial admission to the hospital. As part of regular nursing practice, there are several decisions and actions that were taken that were based on academic and clinical reasoning. The reflective paper will therefore give a general profile of the patient, after which there will be a vivid discussion of the care that was rendered. There will then be an appraisal of the care, which shall take the form of a critical analysis of the care before a reflective conclusion is given. Patient Profile This is the case of Mr. B, whose actual name is withheld for ethical reasons to keep the identity of the patient anonymous. Mr. B was admitted to the hospital for the reason of a post cardiac arrest. This means that the patient was going through a moment of cessation of what was to be the normal circulation of blood into his heart (Sonneville et al., 2013). Such instances of cardiac arrest have been attributed to a failure for the heart to effectively contract and expand as part of its regular functionality (Peberdy et al., 2010). It was realised that Mr. B’s instance of cardiac arrest had come about whiles he was undergoing treatment for acute exacerbation of Asthma in one of the medical ward. Some of the specific instances of symptoms that he showed at the time of being reported to the ward were I was in charge included an arrest with a rhythm of pulseless electrical activity (PEA). It would be noted that under very normal situations, the electrical activation of muscle cells which precede mechanical contraction of the heart brings about regular contraction of the heart (Nolan et al, 2003). In this circumstance of PEA however, the patient experienced total electromechanical dissociation. The situation was determined as the patient’s heart rhythm was observed under the electrocardiogram but in reality, I was not detecting any production of pulse. I was aware any of the 6Hs or 6 Ts namely hypoxia, hydrogen ions, hypovolemia, hyperkalemia, hypothermia, hypoglycaemia, toxins, tamponade, trauma, tachycardia, tension pneumothorax, and thrombosis could be the cause of the PEA and that each of these causes is a very serious situation (Adler, 2013). This made me curious to know much about the medical history of the patient, knowing that the history of the patient was very important for decision making in clinical care. My curiosity was even boasted with the knowledge that almost all the causes of PEA were potential causes of asystole, in which case there is no cardiac electrical activity at all. In the case of asystole, there is absolutely no contraction of the myocardium, which brings about a cut out in blood flow also (Peberdy et al. 2010). Comparing the PEA to Ventricular tachycardia (VT) and ventricular fibrillation (VF), it was noted that quite an opposite situation would be realised in the succession beat per minute (bpm). This is because the VT brings about a ventricular ectopic focus, leading to as many as three or more ventricular extrasystoles taking place at a time. The consequence of the extrasystoles is a record of more than 120 bpm (Finn, Jacobs, Holman and Oxer, 2001). In terms of location also, it would be noted that VT is much focused at the bottom chambers of the heart (Sehati, 2009). In the case of VF, there can be said to be closer relation with the PEA, even though it generally combines symptoms of PEA with those of VT (Finn, Jacobs, Holman and Oxer, 2001). In effect, VF creates uncoordinated contractions, leading to what may be said to be quiver movement of the cardiac muscles of the ventricles rather than a regular contraction. What became particularly worrisome in the case of Mr. B was the fact that pulseless VT and VF have both been found to be present in cardiac arrests where there have been the presence of defibrillator. The suspicion that not tackling the PEA effectively could result in VT and VF was therefore an issue to address. The check indicated that the asthma was a medical condition he had battled for over a decade. The situation was however not given any medical attention in its most early stages and so had partly lead to chronic obstructive pulmonary disease (COPD), which is a disease of the lung, also referred to as chronic obstructive lung disease (COLD) (Arrich, 2007). This means that Mr. B had had several years of poor airflow with some major symptoms including cough, shortness of breath and sputum production on regular basis and in high quantity. Linking the patient’s previous co-morbidities to his present condition, it would be noted that the causes of COPD which the patient was suffering have a direct relation to possible causes of cardiac arrest (Nolan et al, 2003). The same can be said about the long years of asthma that the patient had been battling, most of which years did not receive drastic medical attention. Some of the causes of COPD that are directly linked to risk of cardiac arrest has been found to include smoking, air pollution, occupational exposures and exacerbations (Absalom, Bradley and Soar, 2009). The effect of the previous co-morbidities on the current situation there is that they serve as risk factors for the current health condition of the patient. What is more, a study of the effect of the respiratory system on the circulation system would reveal that because the flow of normal oxidised air is necessary for the effective functioning of the heart, patients with issues with their lungs such as what patient B was going through as a result of asthma and COPD have higher exposure rate to cardiac arrest (Adler, 2013). Knowing the severity of the case, care was rendered in a very proactive and very quick manner made up of a total of 6 hours. The 6 hours was made up of a number of clinical care and interventions which were executed under my watch and with my direct contribution. In the sections following, further details are given on the specific care that was given to Mr. B and how the care are evaluated as either being effective or needing change in future instances. Discussion of Care The care that was given to the patient in the post cardiac arrest state was basically therapeutic hypothermia. It is important to note that this form of nursing intervention was necessitated after 51 minutes of cardio pulmonary resuscitation (CPR) had been performed on Mr. B to ensure that there was return of spontaneous circulation (ROSC). After the ROSC however, Mr. B remained unconscious for very long down time, a reason that led to his transfer to the intensive therapy unit for the therapeutic hypothermia. As noted by Adler J. (2013), therapeutic hypothermia or protective hypothermia is necessary in medical care to ensure that there is the lowering of a patient’s body temperature. Therapeutic hypothermia has also been found to be necessary in protecting the brain against cases of global ischemia for post cardiac arrest patients and others who undergo open-heart surgery (Peberdy et al., 2010). The selection of the use of therapeutic hypothermia was based on the functional changes that the Mr. B had gone through as a result of the cardiac arrest and thus his pathophysiology. The pathophysiology checks on the patient showed that there were reduced cerebral histological deficits after the ROSC and thus the need to achieve improved functional recovery. Meanwhile, Nolan et al (2003) stated that therapeutic hypothermia when issued after ROSC “has been associated with improved functional recovery and reduced cerebral histological deficits in various animal models of cardiac arrest” (p. 120). It was on the basis of such evidence in literature that the therapeutic hypothermia was recommended as the nursing intervention to use as care for Mr. B. Into the specifics of the care and for that matter the therapeutic hypothermia, cooling was began the very moment the patient was brought into the intensive therapy unit (ITU). In relation to Mr. B’s pathophysiology who needed improved rate of long-term neurological intact survival, a target temperature management of 33°C was preferred over 36°C (Peberdy et al. 2010). In order to yield improved neurological outcome in the long term basis for about 6 months, the target temperature management of cooling was targeted to last for a total of 36 hours (Nolan et al, 2003). After the cooling, the patient was intubated and ventilated on synchronised intermittent mandatory ventilation (SIMV/PC). This means that spontaneous ventilation which included pressure support, volume support and continuous positive airway pressure (CPAP) were all undertaken (Adler, 2013). To ensure stability, 100% oxygen was used with the rate of breaths/min set with pressure levels for high and low PEEP at 8. Low BiLevel of I:E ratio of 1:3 was used, accompanied with other variables such as PC at 20, RR of 12 and TV at 340. In the course of the cooling, Mr. B was sedated and paralysed using propofol, ketamine, vecuronium, IV infusion of salbutamol and amynophyline. This particular line of intervention was associated with the patient’s pathophysiology and long history with asthma as Nolan et al. (2003) finds the use of intravenous infusion useful in treating airways obstruction in patients who have cases of severe asthma. This means that there was a general suspicion of the asthma being the direct result of the cardiac arrest which took place and there was also the need to ensure that no cases of unnoticed airways obstructions were taking place while executing the therapeutic hypothermia. Different literature may be reviewed to justify the care that was rendered above in relation to the pathophysiology of the patient and the condition he was going through at the time of the care (Absalom, Bradley and Soar, 2009 and Peberdy et al. 2010). For example inclusion and exclusion criteria that made the patient legible for the therapeutic hypothermia have been discussed by Adler (2013). For example it has been noted that the kind of induced therapeutic hypothermia that was carried out is ideal in patients who have been in coma at the time of cooling (Adler, 2013). Meanwhile, Mr. B was rushed to the ITU for the reason that after 51 minutes of CPR and ROSC, he remained unconscious. Induced therapeutic hypothermia has also been found to be ideal in patients who have the ability to maintain a systolic blood pressure at >90 mm Hg after CPR have been given (Adler, 2013). Meanwhile, Mr. B has showed very stable systolic blood pressure at the time he was taken off the CPR even without pressors. What is more, Adler (2013) advocates the use of induced therapeutic hypothermia in cases where intubated patients are treated within 6 hours after the offset of cardiac arrest. As indicated earlier about Mr. B, he was taken care of in the first 6 hours of his initial admission, meaning that he did not fall out of this inclusion criterion. There are also exclusion criteria that may make the administered care not suitable for the patient. One of these key criteria has to do with patients who have experienced surgery within 14 days but this was not the case of Mr. B. After the various processes of cooling, intubation and ventilation had been performed on Mr. B, there was report from the handover that he had started walking around the ward, eating and drinking as normal. This was an initial sign of the effect of the care but it was not long lasting as a friend who was with him on his bedside noticed chances in his appearance and informed the nurses immediately. As Mr. B was approached by the nurses, he was arrested again. Such instances of re-arrest give concerns for alternative possibilities and strategies that may be considered. In this, Adler J. (2013) noted that use of supportive therapy as an alternative post cardiac arrest patients and especially in cases where multiple morbidities exist as in the case of Mr. B where cases of asthma and COPD were all noticed. In such instance of use of supportive therapy, the major nursing intervention of therapeutic hypothermia may be maintained as the static intervention. But in addition to this, contingency measures have to be taken for the other cases morbidity by engaging in practices such as giving standard neuroprotective strategies like placing the head of the bed at 30° and giving ECG Osbourne or camel wave while cooling is taking place (Alder, 2013). Using secondary temperatire monitoring devices to check patient’s temperature on a regular basis is also prescribed by Alder (2013) at the time that cooling is taking place. This ought to be done to ensure that the need for re-warming resulting from undesirable overcooling does not result (Arrich et al, 2012). Analysis and Appraisal of care Clinical practice has been equated to a learning process, which means that it is continuous exercise that takes place on a constant basis and that the more it happens, the more consolidated it becomes (Storm et. Al., 2012). Because of this, the care was completed on Mr. B with further learning taking place not just from the primary source at the ITU but also through secondary sources by reviewing literature on the use of therapeutic hypothermia in post cardiac arrest patients. Based on the reading from literature, the following findings and analysis may be pointed to as a re-examination of the care that was given. The first line of literature studies was done on why there was arrest after normal recovery had been attained. Literature reviewed showed that incidence of post-resuscitation and myocardial dysfunctions that lead to death are very high in resuscitated patients (José et al, 2012). Upon review, there was the realisation that very little provision of any kind was made towards the prevention of post-resuscitation and myocardial dysfunction after resuscitated had been achieved. The emphasis of the nursing team seemed to have been more focused on using therapeutic hypothermia to achieve resuscitation and the cooling of temperature in the most immediate while. Meanwhile, Finn, Jacobs, Holman and Oxer (2001) noted that post-resuscitation myocardial dysfunction continues to act as one of the leading causes of death and not just re-arrest after successful resuscitation have been achieved. Further review of literature showed that the reason this situation exists is because of left ventricular systolic dysfunction, which gets impaired after both cardiac arrest and cardiopulmonary resuscitation (Oddo et al, 2010). Meanwhile, casting back to the care that was given, no provisions were made to contain the incidence of left ventricular systolic dysfunction after the resuscitation was achieved. With the revelation on why re-arrest was experienced by Mr. B and how the situation could actually have resulted in early death after the resuscitation, further review of literature that was focused on ways of minimising post-resuscitation brain and myocardial dysfunction. The emphasis was placed on brain and myocardial dysfunction at the same time, following preliminary review of literature which had showed a direct correlation between the neurological system and the circulation system (Hachimi-Idrissi et al., 2001). Meanwhile, there has also been found to be a relationship between SIRS, sepsis and MODS, and the neurological system (Sandroni, Cavallaro and Antonelli, 2013). This means that the focus of the nursing intervention should have also looked at multi-organ failure in addition to brain injury. The very first finding that was made from secondary literature which had a direct relation to the care that was executed to Mr. B was the fact that in order to ensure reduction in early mortality caused by multi-organ failure and brain injury, we should have undertaken post-cardiac arrest care as a collective practice rather than merely engaging in therapeutic hypothermia. As part of the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science, Peberdy et al (2010) noted that most nurses have refused to appreciate the fact that post-cardiac arrest care is a collective practice that embodies other specific interventions such as therapeutic hypothermia. Because of this, such nurses jump the gun by thinking of therapeutic hypothermia as a conclusive care when in actual fact, it should only be part of the collection of care practices. From the assertion made by Peberdy et al (2010), the realisation that is made for care that was delivered is that, there should have been two major sets of objectives set to achieve the collective goal of post-cardiac arrest care, under which the use of therapeutic hypothermia would have fallen. The first set of objectives is what has been described as initial objectives of post-cardiac arrest care. Under this, three major roles could have been played, the first of which would have been to optimise cardiopulmonary function, as well as the perfusion of vital organ. This should have been followed with the task of combining the use of acute coronary interventions, neurological care, and hypothermia at the same time (Peberdy et al, 2010). In my case however, it would be noted that all that which was emphasised was the hypothermia care. The last stage of the initial objectives of post-cardiac arrest care should be made up of the identification and treatment of precipitating causes of arrest and prevention of recurrent arrest as noted in Peberdy et al (2010). In our case however, this last objective was only partly fulfilled where I adequately identified the precipitating cause of Mr. B’s cardiac arrest and rightly related it to his pathophysiology. There is a second set of objectives in post-cardiac arrest care described as subsequent objectives of post-cardiac arrest. From an analytical point of view, it would be noted that some of the subsequent objectives of post-cardiac arrest were followed while others were ignored. For example, literature has showed the need to control body temperature as a way of optimising survival and achieving neurological recovery (Whitfield, Coote and Ernest, 2009). As part of the therapeutic hypothermia intervention that was used, this particular role was adequately taken care of. But as the control of body temperature takes place, the need to identify and treat causes of acute coronary syndrome (ACS) has also been found to be an important way preventing re-arrest. The reason this process would have been particularly important for Mr. B is the fact that he had history of COPD, which is directly associated with obstruction of the coronary arteries, which is the exact case in acute coronary syndrome (Absalom, Bradley and Soar, 2009). Another important process as part of the second set of objectives has been noticed to be the optimisation of mechanical ventilation as way of minimising lung injury (José et al, 2012). This was also something that was undertaken in the case of Mr. B even though the method used was not conventionally mechanised but by use of SIMV. Last but not least, Whitfield, Coote and Ernest (2009) advised on the reduction of risk of multi-organ injury and support for organ function where necessary. This was also another area that was not taken care of in the care of Mr. B. This could be a possible cause of the re-arrest, which might have come about as a result of Mr. B, developing multi-organ injuries that had not come to attention as early as possible. Personal Reflection After every major care such as the one that I executed, the question of what would be done differently based on primary and secondary learning is an important one for the nurse. On the question of how the care has impacted my own professional practice, a lot can be mentioned. First of all, the care given and the secondary learning that took place thereafter has given me in-depth knowledge on the subject of post-cardiac arrest care as a collective paradigm aimed at bringing improved health to patients. This is because while assigned to my care, my most prioritised focus was to use the specific nursing intervention I had in mind as the solution for the problem presented the patient. Today, I have come to appreciate the importance of holistic and integrated care as against the use of segregated or refined care. Another area of professional practice that the care I gave have impacted has to do with the area of providing immediate follow up for my patients who are given care and begin showing signs of recovery. Follow up care has been identified to be an important responsibility for the nurse, aimed at bringing the nurse up to speed with what is going on in the system of the patient on a time to time basis (Nolan et al., 2003). Even though follow up care may not be part of the defined role of the nurse for a particular patient, I have come to realise that in nursing care, the end justifies the means and that it is important to have a personal goal to take the patient through the care process through up to the time that they eventually leave the hospital. The care that was rendered has also shaped my learning needs in a lot of ways. As reflected in what I have gained in my professional practice, I have come to realise that one of my most crucial learning needs is integrated and holistic learning. This is because it is only when I undertake integrated and holistic learning that I shall have the knowledge needed to execute or render integrated and holistic care. One weakness of my current learning that this care has exposed is that once I know I am supposed to use a particular nursing intervention for a specific situation such as the use of therapeutic hypothermia for post-cardiac arrest, I limit my research and learning on that area with the hope of mastering that aspect very well. This has however proven not to be very effective as there is the need for me to widen my learning base and ensure that a lot more related areas of my interventions are covered in learning. This is because once I am able to put together as many areas of learning as possible, I shall be better placed to quick place to switch care to a more integrated one when the need arises in the time of rendering care. Again, I have come to realise that will help my learning needs is to engage more in group learning and practice as against independent learning and practice. This is because in group learning, the probability that there will be positive and relevant exchange of knowledge, skills and experience from one person to the other is higher. Such a process will generally expand my scope of ideas on specific patient care situations and put in a ready-armed position to render care that will be timely and precise to customer needs. Into the future, I am expecting a lot of changes in my nursing practice based on the evidence that have been gathered in this reflective paper. More specifically, much attention will be given to integrated care and the need to follow up closely on patients rate of discover, whether or not I am personally assigned to do so. This means that I am going to have an awakened to nursing care as a calling rather than an ordinary profession. Conclusion This has been a reflective account on care that I gave to 45 year old Mr. B who was brought to the ITU for resuscitation after experiencing cardiac arrest whiles receiving treatment for his asthma condition. The nursing intervention taken towards helping Mr. B was therapeutic hypothermia. As a result, several specific care processes were performed including the cooling of the patient and ensuring stabilisation of blood levels. As part of the pathophysiology of the customer, the need to ensure protection was his neurological performance was also undertaken. In a very short while, the intervention proved effective as patient gained resuscitation and started walking about, eating and drinking as usual. This however did not last for long as a friend noticed changes in the appearance of Mr. B, shortly after which he experienced arrest. Upon critical analysis of the care, it can be concluded that there was lack of integrated care, even though therapeutic hypothermia was executed very extensively. Studies that were reviewed after the care have showed the need to have been more particular and concerned about other issues such as brain injury, given that the neurological system has a direct effect on the circulatory system. The need for there to have been greater care for multi-organ dysfunction while undertaking the therapeutic hypothermia has also been realised (Absalom, Bradley and Soar, 2009). This is because the history of the customer on COPD further exposed him to acute coronary syndrome, which could have arisen at any point in time at all while undergoing therapeutic hypothermia. References Absalom AR, Bradley P & Soar J. (2009). ‘Out-of-hospital cardiac arrests in an urban/rural area during 1991 and 1996: have emergency medical service changes improved outcome’? Resuscitation. 40(1): pp. 3–9. These are authors who have had a series of works published with the Resuscitation Journal, which is a very credible academic health journal used by most universities across Europe and America. The source was included due to its quality in discussing emergency medical service situations. The source was particularly included in the study to address the issue of out-of-hospital cardiac arrest interventions. This is because the authors argue that patients require different levels of professional attention when they are out of the hospital as against when they are already in-patients. Adler J. (2013). Therapeutic Hypothermia. [Online] Available from http://emedicine.medscape.com/article/812407-overview [27th February 2014] This e-medicine journal is an online journal with many years of credible academic publications on cardio health interventions. Apart from the credibility of the journal, the author, whose work was selected, has also been a practicing therapeutic health provider with several years of experience. The source was particularly selected as it makes new claims about cooling as against re-warming as part of interventional care given to patients who readily have recovered from cardiac arrest. Since a similar intervention was used for Mr. B, the source was selected for insight. Arcure, J & Harrison, E. E. (2009). ‘Review Article of the Use of Early Hypothermia in the Treatment of Traumatic Brain Injuries’. Journal of Special Operations Medicine. 10(3): pp. 22–5. These are two authors who have had several publications, not only with the Journal of Special Operations Medicine, but also with other reputable academic journals. Coupled with the fact that both authors are practitioners, their inputs may be trusted as credible. The source was selected for the very reason that it focuses on the argument that hypothermia is needed in early cases of cardiac arrest recovery. The source also relates hypothermia to neurological functions and claims that hypothermia could be used in the treatment of traumatic brain injuries. This source was therefore selected to ascertain how Mr. B would benefit from in relation to neurological recovery. Arrich J (2007). ‘Clinical application of mild therapeutic hypothermia after cardiac arrest’. Crit Care Med, 35(3): pp. 1041-1047. Arrich has been a regular contributor to Critical Care Medicine and has had most of his work cited by other authors who have had their work published in other reputable journals. It was for this reason his source was considered reputable. The quality of arguments in relation to clinical observations that ought to be considered when undertaking clinical application of mild therapeutic hypothermia was the very reason this source was included. Including this source meant knowing exactly what to do right during therapeutic hypothermia so as to avoid any unforeseen mistakes. Arrich J, Holzer M, Havel C, Müllner M, & Herkner H. (2012). ‘Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation’. Cochrane Database Syst Rev. 12(9): pp. 4-128. Arrich had independently contributed to this journal but was this time joining forces with other independent writers as a way of improving the credibility of their outcome. In this particularly work, there was a direct relationship between hypothermia and neuroprotection. The writers argued that hypothermia is necessary and useful for neuroprotection in adults after cardiopulmonary resuscitation. Given the fact that Mr. B might have suffered some neurological functional defects after his resuscitation, this source was included to ascertain how Mr. B might benefit from neuroprotection following hypothermia. Finn JC, Jacobs IG, Holman CD & Oxer HF (2001). ‘Outcomes of out-of-hospital cardiac arrest patients in Perth, Western Australia, 1996–1999’. Resuscitation. 51(3): pp. 247–255. These are researchers who had undertaken a 3 year long study of out-of-hospital post cardiac arrest patients in Perth. The credibility of their work is in the fact that it does not only emphasise short term results but focuses directly on long term outcomes taken as a result of follow up of subjects. This source was included as a quality source of information on how post-resuscitation life was going to be for Mr. B. This was particularly necessary as the patient was noted to have started showing signs of improvement shortly after treatment. Hachimi-Idrissi S, Corne L, Ebinger G, Michotte Y & Huyghens L (2001).  ‘Mild hypothermia induced by a helmet device: a clinical feasibility study’. Resuscitation, 51(3): pp. 275-281. The input of these writers were sought as a credible source for the author’s assignment given the fact that they have had a series of articles published in this journal and others. What is more, they have had a lot of other writers periodically referencing their work. The source focused on mild hypothermia induced by a helmet device. The interest of the researcher in relation to this source was that there could be improvisation during hypothermia as the study looked into the clinical feasibility of a helmet device for induced mild hypothermia. José G. C, Jane H. B, Valerie J. M, Brent M. & Hinchey P. R (2012). ‘Field-induced Therapeutic Hypothermia for Neuroprotection after Out-of Hospital Cardiac Arrest’. J Emerg Med.; 40(4): pp.400-409. These are writers whose work has had academic and professional commendation, for which reason they have constantly been quoted by other writers publishing in credible academic journals. The source was selected particularly as a contradictory literature source that argued for the use of therapeutic hypothermia for neuroprotection purposes. This is because the source noted that even though therapeutic hypothermia can be used for neuroprotection, this does not always happen following out-of-hospital cardiac arrest. Nolan J.P et al. (2003). ‘Therapeutic Hypothermia After Cardiac Arrest’. Circulation. 80(2); pp. 118-121. The credibility of the work of these writers is that they are not only practicing authors but are also editors for the journal. This demonstrates the depth of knowledge they have in the area of cardiac care. Their source was included to serve the purpose of answering all questions that had to do with best practices while engaging in therapeutic hypothermia. It was actually from this source that the importance of other health risks that could have affected Mr. B should have been observed for. The source was therefore important in expanding my personal reflection as a practitioner. Oddo M, Schaller MD, Feihl F, Ribordy V & Liaudet L (2010).  ‘From evidence to clinical practice: effective implementation of therapeutic hypothermia to improve patient outcome after cardiac arrest’. Crit Care Med, 34(1): pp.1865-1873. The credibility in this source was taken from the fact that the researchers spent several years finding evidence on very basic practices and actions taken during therapeutic hypothermia that may undermine successful improvement in patient outcome after cardiac arrest. After this, a set of clinical practices were advocated. The source was therefore included to learn from these evidence based clinical practices to be used in the care of Mr. B. Peberdy M.A. et al. (2010). ‘2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science’. Circulation.  122(3): pp. 768-786 This source was considered credible as it did not only provide the outcome of a single researcher but as a guide for the entire American Heart Association. It was for this reason that this source was used more than any other source. The source was helpful in establishing best clinical practices for cardiopulmonary resuscitation and emergency cardiovascular care. Notably, the patient had gone through resuscitation and so it was important to learn from such an authoritative source as the American Heart Association on what should comprise best practice. Sandroni C, Cavallaro F & Antonelli M (2013). ‘Therapeutic hypothermia: is it effective for non-VF/VT cardiac arrest’? Critical Care, 17(3): pp. 215 As part of the care given to Mr. B, he had been diagnosed as exhibiting non-VF/VT cardiac arrest. For this reason, it was necessary to have a source that differentiated non-VF cardiac arrest from other forms of cardiac arrest. This source was there consider very useful in serving this purpose. One factor that influenced the credibility of this source was the fact that all writers are practicing registered nurses with several years of experience in this area of study. Sehati, N. (2009). Nervous System Anatomy and Physiology. [Online] Available from http://sehati.org/index/patientresources/normalanatomy.html [January, 24, 2014] This is an online resource that has served as a credible academic and practical source for many years. The site is frequently updated and only open to authors whose background in neurology can be authenticated. The source was particularly included to help establish the relationship that existed between the cardiac inefficiencies of the patient and the functioning of his nervous system. Sonneville R. et al (2013). ‘Understanding brain dysfunction in sepsis’. Annals of Intensive Care, 3(15). Pp. 23-43 This source had argued that there is a direct relationship between brain dysfunction and sepsis, and thus other functional defects such as cardiac arrest. It was for this reason this source was included in the study as a way of gaining in-depth insight into all variables that could possibly be a part of why the patient was experiencing the kind of cardiac unrest he was going through. The credibility of this source can be directly related to the journal in which it was published, which is a very credible journal of intensive care, used by several universities in Europe. Storm C, Nee J, Roser M, Jorres A. & Hasper D. (2012). ‘Mild hypothermia treatment in patients resuscitated from non-shockable cardiac arrest’. Emerg Med J, 29(2): pp. 100-103. These are writers who have made a lot of contributions to other medical emergency journals and have had their work referenced by several other writers. The source clearly distinguishes mild hypothermia treatment given to patients with non-shockable cardiac arrest from those with shockable cardiac arrest. The source was thus useful in establishing the fact that the case of Mr. B could not be generalised but needed to be specifically distinguished. Whitfield AM, Coote S & Ernest D. (2009). ‘Induced hypothermia after out-of-hospital cardiac arrest: one hospitals experience’. Crit Care Resusc, 11(2): pp. 97-100. This was a case study, which was considered very credible for this assignment as it was very emphatic in using results of a case study that had been performed in only one hospital. Because the approach of the writers was a case study, it could be trusted to be one that was carefully attended to and specifically detailed according to the case at hand. The source was useful in this study in understanding risk factors to look out for while engaging in induced hypothermia in the case of out-of-hospital cardiac arrest.     Read More