How to Stay Cool in the Intensive Care Unit? Endovascular Versus Surface Cooling.

Abstract

Dozens of observational studies published over the past 2 decades have shown that fever in patients with acute neurological injury, regardless of its cause, is independently linked to higher mortality, poor neurological outcome, and increased length of stay in the intensive care unit and hospital. This has been demonstrated for traumatic brain injury, acute ischemic stroke, subarachnoid hemorrhage, intracranial hemorrhage, and cardiac arrest (CA).1,2 Therefore, therapeutic temperature management is a key goal of care in all patients with acute brain injury. In most cases the goal is strict fever control, ie, controlled normothermia; in patients with posthypoxic injuries, the goal is often to achieve below-normal core temperature, ie, to induce therapeutic hypothermia. Article see p 182 Therapeutic hypothermia has been studied extensively in newborns with neonatal asphyxia and in adults with hypoxic injury following witnessed CA.1 A “heated” debate is currently going on regarding optimal target temperature after CA. Current guidelines recommend 32°C to 34°C,3 based on 2 randomized, controlled trials (RCTs) published in 2002 and numerous before-after studies, and indirect evidence from 7 multicenter RCTs in perinatal asphyxia.1,4 A small RCT published in 2012 comparing 2 temperature regimens after witnessed CA reported significantly better outcomes with 32.0°C in comparison with 34.0°C.5 In contrast, a large RCT published in 2013 (the targeted temperature management trial) found no difference between strict temperature control at 36.0°C in comparison with 33.0°C.6 The conclusions of this study have been criticized by various authors (including the undersigned) for problems such as potential selection bias, prolonged time (10 hours) to target temperature, temperature fluctuations during the maintenance phase, excessively rapid rewarming, and other issues.4,7–10 This topic continues to be debated; however, although there is disagreement on the optimal temperature (32, 33, …