In our PICU we use an external cooling system Blanketrol with a protocol of rapid induction and maintenance during 48 h. We controlled rewarming with a rate of 0,5°C /2h .
We currently just do adults (there is a trial in our PICU), and do 24 hours at 33 degrees and then 24 hours of controlled re-warming to 37. We use an endovascular device.
http://sitemaker.umich.edu/big/files/um_innercool_guideline_april2010.pdf
We currently start induction with 4°C saline infusion (1-2l) so you are able to bring patient to cath lab or CT-scan without another device. After that we continue with external cooling device (Blanketrol II) with an target temperature of 33°C for 24h . After that rewarming is done with 0.3°C/h. But this protocol like every other protocol is not based on evidence. So far we do not have clear data that faster cooling is better (concerning neurological outcome). The same problem with rewarming procedure.
In fact some smaller sudies suggest that not the hypothermia is beneficial but the maintenance of a normal body temperature around 37°C. Highest priority seems to hinder fever in these patients after ROSC. Further studies or registers are on the way:
Target Temperature Management After Cardiac Arrest Trial www.clinicaltrials.gov NCT01020916
We use an intravascular (femoral vein) cooling device. I agree cold saline in the ED is a good way to start the ball rolling. We cool to 33 C for 24 hours. We rewarm at 0.25-0.5C/hour to 36 C and hold there for 6 hours or so then allow passive temperature changes. We leave the intravascular catheter in place and control the temperature to not exceed 37 for a further 24 hours as post-rewarming hyperthermia is very common and likely not positive. We also apply balanced cutaneous counterwarming (forced air) which we find really cuts down on shivering and minimises metabolic changes without diminishing the cooling efficacy. We don't routinely paralyse the patients beyond a single bolus at induction of hypothermia if there is shivering, and we maintain sedation with propofol and remifentanil.
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