TY - JOUR
AU - MD, Jeremy Goverman,
AB - Abstract This case report describes a complication caused by cooling pads used for therapeutic hypothermic resuscitation. The authors hope to highlight and emphasize the importance of a thorough evaluation of all skin surfaces that are in direct contact with such cooling pads. Skin injury from the cooling pads used for therapeutic hypothermia should be recognized as a potential complication of treatment. Therapeutic hypothermia has become a standard of care for neuroprotection in patients after cardiac arrest; however, there is no information on the adverse effects and complications of this treatment. The most common method used to induce therapeutic hypothermia involves the use of surface cooling pads that are coated with hydrogel. These pads adhere to the patient's abdomen, back, and thighs, allowing for direct thermal conduction through the skin. Proper usage of this system includes routine evaluation of the skin surfaces to which the pads are adhered in order to prevent skin injuries. This case report highlights an adverse outcome to the skin from use of the ARCTIC Sun device. CASE REPORT Before Transfer to Massachusetts General Hospital A 24-year-old, male, diabetic patient presented to an outside hospital with abdominal pain and increased transaminases. His hospital course involved three episodes of cardiac arrest for which therapeutic hypothermia was initiated. The initial induction of therapeutic hypothermia was interrupted by abdominal compartment syndrome requiring removal of the abdominal cooling pads for urgent bedside abdominal decompression. Shortly thereafter, he suffered a second cardiac arrest for which the cooling protocol was reinitiated after advanced cardiac life support protocol restored vital signs. On hospital day 3, the surgical team explored the abdomen at the bedside and performed a primary fascial closure; however, on hospital day 4, the patient suffered his third cardiac arrest, requiring advanced cardiac life support and therefore the cooling protocol was again reinitiated. Throughout this time period, the cooling pads on the thighs were left in place. As a result of the abdominal decompression and the additional two cardiac arrests, the cooling process was interrupted before reaching maximal cooling temperatures. The rewarming process of the therapeutic hypothermia did not actually occur until hospital day 5. At this point, the patient remained with multiorgan dysfunction and was transferred to our institution. After Transfer to Massachusetts General Hospital The patient was transferred to the surgical intensive care unit for stabilization and further workup of hepatitis of unknown cause. The burn service was consulted to evaluate skin injuries noted to his bilateral thighs. An examination revealed that there were areas of necrotic skin and erythema present on bilateral thighs circumferentially (Figure 1). The total body surface area involved was approximately 15%. On the day after transfer, the patient was taken to the operating room for excisional debridement. Full-thickness necrosis of skin and underlying subcutaneous tissue was noted with patchy areas of deep muscle necrosis (Figure 2). Wounds were debrided, dressings were applied, and the patient returned to the surgical intensive care unit where, in light of his ongoing multiorgan dysfunction, the goals of care were changed to comfort measures only, and the patient expired. Figure 1. View largeDownload slide Initial evaluation of bilateral thighs third-degree burns. A, Anterior surface. B, Posterior surface. Figure 1. View largeDownload slide Initial evaluation of bilateral thighs third-degree burns. A, Anterior surface. B, Posterior surface. Figure 2. View largeDownload slide Intraoperative findings. A, Necrotic thigh muscles through deep investing fascia. B and C, Necrosis involving all compartments. D, Sparing of lower leg involvement upon exploration. Figure 2. View largeDownload slide Intraoperative findings. A, Necrotic thigh muscles through deep investing fascia. B and C, Necrosis involving all compartments. D, Sparing of lower leg involvement upon exploration. DISCUSSION In the setting of cardiac arrest, therapeutic hypothermia is neuroprotective and has been shown to improve overall mortality.1,2 Selection of patients for therapeutic hypothermia includes cardiac arrest with ventricular fibrillation/ventricular tachycardia as the initial rhythm. This recommended criteria has been expanded to include those in arrest with asystole or pulseless electrical activity. Contraindications to therapeutic hypothermia include multiorgan dysfunction and severe sepsis. An abstract presented at the 2006 American Heart Association Scientific Session found a higher mortality rate with therapeutic hypothermia in diabetic patients when compared with that of nondiabetic patients.3 An extensive review of the English literature yields no reports of skin injury from therapeutic cooling. A case report of subcutaneous fat necrosis in neonates, as a possible side effect of therapeutic hypothermia used for encephalopathy, has been reported.4 In that case report, the authors hypothesized that cold stress, or ischemic injury, to the immature fat cells resulted in necrosis and solidification. The only other significant side effect noted for patients undergoing therapeutic hypothermia was seizures, and for this reason concurrent EEG monitoring has been suggested. As demonstrated here, skin and soft tissue injury from direct contact of the cooling pads to the body surfaces is a legitimate concern. There is no standard protocol for checking the skin when using cooling pads. There are reports that the nursing staff check the skin every hour (verbal communication via intensive care unit nurses) at some institutions as compared with a feasibility and efficacy study that reported checking the skin every 8 hours as being sufficient.5 Our patient's presenting illness was complicated with an underlying systemic illness that limited the standard protocol placement of the cooling pads to the thighs only. The cooling pads are designed to cool large surfaces including the trunk and thigh. Concerns for skin injury are often refuted in that the large surface area of distribution allows for even cooling in order to avoid potential soft tissue injury. Nevertheless, this case report illustrates a complication of therapeutic hypothermia via the ARCTIC Sun device, which included full-thickness skin necrosis with underlying myonecrosis. Such skin and muscular injury should be considered as a potential side effect of therapy, and therefore guidelines on the use of hypothermia devices must be followed and should include frequent evaluation of cooling pad contact points. REFERENCES 1. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346:557–63. 2. Nolan JP, Morley PT, Vanden Hoek TL, et al.International Liaison Committee on Resuscitation. Therapeutic hypothermia after cardiac arrest: an advisory statement by the advanced life support task force of the International Liaison Committee on Resuscitation. Circulation. 2003;108:118–21. 3. Ploj T, Groselj U, Kavcic M, Noc M. Is therapeutic hypothermia after cardiac arrest harmful for diabetic patients? Circulation. 2006;114:II_1191. 4. Woods AG, Cederholm CK. Subcutaneous fat necrosis and whole-body cooling therapy for neonatal encephalopathy. Adv Neonatal Care. 2012;12:345–8. 5. Haugk M, Sterz F, Grassberger M, et al. Feasibility and efficacy of a new non-invasive surface cooling device in post-resuscitation intensive care medicine. Resuscitation. 2007;75:76–1. Copyright © 2013 by the American Burn Association
TI - Skin Necrosis as a Complication of Therapeutic Hypothermia
JO - Journal of Burn Care & Research
DO - 10.1097/BCR.0b013e3182a22730
DA - 2014-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/skin-necrosis-as-a-complication-of-therapeutic-hypothermia-4PD3pfxWPk
SP - e184
EP - e186
VL - 35
IS - 3
DP - DeepDyve
ER -