Temperature Management In Patients Research Articles

Targeted temperature management in patients undergoing extracorporeal life support after out-of-hospital cardiac arrest: an EURO-ELSO 2018 annual conference survey.

Targeted temperature management and extracorporeal life support, particularly extracorporeal membrane oxygenation in patients undergoing cardiopulmonary resuscitation, represent outcome-enhancing strategies for patients following in- and out-of-hospital cardiac arrest. Although targeted temperature management with hypothermia between 32°C and 34°C and extracorporeal cardiopulmonary resuscitation bear separate potentials to improve outcome after out-of-hospital cardiac arrest, each is associated with bleeding risk and risk of infection. Whether the combination imposes excessive risk on patients is, however, unknown.

Prolonged targeted temperature management in patients suffering from out-of-hospital cardiac arrest.

We are very thankful for all the comments and interest that our publication (1) has generated. Overall, we agree with most of the issues raised in the editorials (2-4); however, we would like to make further comments on some of them.

Targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke: consensus recommendations

BackgroundA modified Delphi approach was used to identify a consensus on practical recommendations for the use of non-pharmacological targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke with non-infectious fever (assumed neurogenic fever). MethodsNine experts in the management of neurogenic fever participated in the process, involving the completion of online questionnaires, face-to-face discussions, and summary reviews, to consolidate a consensus on targeted temperature management. ResultsThe panel's recommendations are based on a balance of existing evidence and practical considerations. With this in mind, they highlight the importance of managing neurogenic fever using a single protocol for targeted temperature management. Targeted temperature management should be initiated if the patient temperature increases above 37.5°C, once an appropriate workup for infection has been undertaken. This helps prevent prophylactic targeted temperature management use and ensures infection is addressed appropriately. When neurogenic fever is detected, targeted temperature management should be initiated rapidly if antipyretic agents fail to control the temperature within 1 h, and should then be maintained for as long as there is potential for secondary brain damage. The recommended target temperature for targeted temperature management is 36.5–37.5°C. The use of advanced targeted temperature management methods that enable continuous, or near continuous, temperature measurement and precise temperature control is recommended. ConclusionsGiven the limited heterogeneous evidence currently available on targeted temperature management use in patients with neurogenic fever and intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke, a Delphi approach was appropriate to gather an expert consensus. To aid in the development of future investigations, the panel provides recommendations for data gathering.

Esophageal Heat Transfer for Patient Temperature Control and Targeted Temperature Management

Controlling patient temperature is important for a wide variety of clinical conditions. Cooling to normal or below normal body temperature is often performed for neuroprotection after ischemic insult (e.g. hemorrhagic stroke, subarachnoid hemorrhage, cardiac arrest, or other hypoxic injury). Cooling from febrile states treats fever and reduces the negative effects of hyperthermia on injured neurons. Patients are warmed in the operating room to prevent inadvertent perioperative hypothermia, which is known to cause increased blood loss, wound infections, and myocardial injury, while also prolonging recovery time. There are many reported approaches for temperature management, including improvised methods that repurpose standard supplies (e.g., ice, chilled saline, fans, blankets) but more sophisticated technologies designed for temperature management are typically more successful in delivering an optimized protocol. Over the last decade, advanced technologies have developed around two heat transfer methods: surface devices (water blankets, forced-air warmers) or intravascular devices (sterile catheters requiring vascular placement). Recently, a novel device became available that is placed in the esophagus, analogous to a standard orogastric tube, that provides efficient heat transfer through the patient's core. The device connects to existing heat exchange units to allow automatic patient temperature management via a servo mechanism, using patient temperature from standard temperature sensors (rectal, Foley, or other core temperature sensors) as the input variable. This approach eliminates vascular placement complications (deep venous thrombosis, central line associated bloodstream infection), reduces obstruction to patient access, and causes less shivering when compared to surface approaches. Published data have also shown a high degree of accuracy and maintenance of target temperature using the esophageal approach to temperature management. Therefore, the purpose of this method is to provide a low-risk alternative method for controlling patient temperature in critical care settings.

Clinical Evaluation of Fluido Compact<sup>®</sup>: A New Intravenous Fluid Warmer

Unintended peri-operative hypothermia is very common in surgical patients and is associated with adverse outcomes. Perioperative use of forced-air and intravenous fluid warmers is recommended for hypothermia prevention. This study evaluated the ease of use of Fluido® Compact, a new fluid warming device, and its ability to help as part of the intraoperative patient temperature management. It was used in 36 patients undergoing scheduled surgery at risk of hypothermia under regional, general or combined anesthesia, of more than one hour duration and with a predicted intravenous fluid administration of at least 1000 ml. The fluid warmer is very easy to set up. The disposable cassette has a very low (3 ml) priming volume and it is easy to handle and to place inside the warming module. Once connected to the main power outlet, it is ready to deliver fluid at target temperature in just a few seconds. Control panel is intuitive, and the one button operation system makes it safe and convenient. The combination of peri-operative patient surface warming with Mistral®-Air forced-air warming system and intravenous fluid warming with Fluido® Compact, that allowed the administration of IV perfusions at body temperature at the rate needed thus avoiding heat loss, helps to maintain intraoperative core temperature between 36.4°C and 36.8°C. A group of patients undergo a variety of surgical procedures with neuraxial, general or combined epidural-general anesthesia.

“What’s the Risk?” Assessing and Mitigating Risk in Cardiothoracic Surgery

“What’s the Risk?” Assessing and Mitigating Risk in Cardiothoracic Surgery

Clinical outcomes of 3-year experience of targeted temperature management in patients with out-of-hospital cardiac arrest at Songklanagarind Hospital in Southern Thailand: an analysis of the MICU-TTM registry.

BackgroundOut-of-hospital cardiac arrest (OHCA) is one of the leading causes of intensive care unit admission, which results in high hospital mortality. Targeted temperature management (TTM) was introduced several years ago and is considered to improve neurological and mortality outcomes. This management process was implemented in our hospital in 2012, which was expected to improve the standard of care in OHCA patients.PurposeWe aimed to report the clinical and mortality outcomes after TTM was introduced to our hospital in 2012.Patients and methodsAn analysis of data from the Medical Intensive Care Unit-TTM registry between 2012 and 2015 was performed. After successful cardiopulmonary resuscitation, TTM was applied to all OHCA patients regardless of causes if there was no contraindication. The Cerebral Performance Category scale score and other clinical outcomes were recorded and analyzed.ResultsOut of 23 patients, 87% were male and the mean age was 54.5±18.1 years. The causes of OHCA from cardiac etiology comprised 52.2%. The most common initial cardiac rhythm was ventricular fibrillation (47.8%). The survival rate to hospital discharge was 47.8% (11/23), but neurological outcomes were in a persistent vegetative state (8/11, 72.7%). The group with poor neurological outcomes had a significantly higher Acute Physiologic Assessment and Chronic Health Evaluation II score than the group with good neurological outcomes (22.9±4.2 vs 16.0±3.6, P=0.01). In the multivariate analysis, initial shockable rhythm was associated with survival at hospital discharge (odds ratio 10.1, 95% confidence interval 1.1–94.3, P=0.04).ConclusionTTM in OHCA patients gave better mortality benefits compared to our previous records, despite poor neurological outcomes. Ventilator-associated pneumonia was the major complication of TTM. Therefore, TTM should be considered in OHCA patients, especially in shockable rhythms, after return of spontaneous circulation.

Plasma Potassium Concentration on Admission Correlates with Neurologic Outcome in Traumatic Brain Injury Patients Treated with Targeted Temperature Management: A Post Hoc Analysis of a Multicenter Randomized Controlled Trial

Recent studies have focused on the association between plasma electrolytes, particularly potassium level and neurologic outcomes in patients with traumatic brain injury (TBI). We hypothesized that potassium level on admission is an indicator for initiation of targeted temperature management in patients with severe TBI. We re-evaluated the Brain Hypothermia Study data based on the potassium levels on admission (i.e.,hypokalemia [<3.5 mEq/L] or normokalemia [3.5-5 mEq/L]) and compared these values and Glasgow Outcome Scale scores at 6 months by per protocol analysis. Consequently, 135 patients were enrolled. Finally, groups 50 and 23 patients with hypokalemia and 34 and 23 patients with normokalemia were allocated to mild therapeutic hypothermia (MTH) and fever control groups, respectively. Baseline characteristics, complication rates, and favorable neurologic outcome rates were compared between the two groups. In the normokalemia patients, fever control management was associated with a significant increase in favorable neurologic outcome compared with those in the MTH group (68.2% vs. 35.3%; P= 0.03). The complication rate was significantly higher in the MTH group than in the fever control group for patients with normokalemia (23.4% vs. 0%; P= 0.03). Conversely, hypokalemia patients in the MTH group revealed relatively better favorable neurologic outcomes compared with those in the fever control group (52.0% vs. 39.1%; P= 0.33). The initial potassium level may be an indicator in determining appropriate targeted temperature management for patients with TBI. Fever control may be considered instead of MTH for normokalemia patients with TBI on admission.

Response to Letter Regarding Article, “The Utility of Therapeutic Hypothermia for Post–Cardiac Arrest Syndrome Patients With an Initial Nonshockable Rhythm”

Thank you for the opportunity to respond to Dr Chan’s insightful comments regarding our article, “The Utility of Therapeutic Hypothermia for Post–Cardiac Arrest Syndrome Patients With an Initial Nonshockable Rhythm.”1 In this article, we used propensity score matching in a quasi-experimental design to mimic a randomized, controlled trial. Propensity score analyses have been both promoted and criticized in the literature, with a known limitation being the impact of unmeasured variables; however, there have been no published randomized trials of targeted temperature management versus no temperature management for patients with initial nonshockable rhythms because of various barriers. Our analysis, which included 519 patients with an initial nonshockable rhythm from the Penn Alliance for Therapeutic Hypothermia (PATH) Registry between 2000 and 2013, was …

The Role of Targeted Temperature Management in Adult Patients Resuscitated from Nonshockable Cardiac Arrests: An Updated Systematic Review and Meta-Analysis.

Routine targeted temperature management is recommended for comatose adult patients with return of spontaneous circulation after cardiac arrest. However, the role of targeted temperature management in patients resuscitated from nonshockable cardiac arrests remains uncertain. We conducted an updated systematic review and meta-analysis to evaluate the effects of targeted temperature management in this population. Medline, EMBASE, and Cochrane databases were systematically reviewed for studies published between January 2005 and March 2016, in which targeted temperature management was compared with standard care or normothermia for adult patients resuscitated from nonshockable cardiac arrests. A total of 25 trials that included 5715 patients were identified from 10985 relevant papers. Pooled data showed that targeted temperature management not only associated with improved short-term survival (RR = 1.42, 95% CI: 1.28–1.57) and neurological function (RR = 1.63, 95% CI: 1.39–1.91) but also associated with improved long-term survival (RR = 1.64, 95% CI: 1.27–2.12) and neurological recovery (RR = 1.42, 95% CI: 1.07–1.90) in observational cohort studies. However, more frequent infectious complications were reported in hypothermia-treated patients (RR = 1.46, 95% CI: 1.26–1.70) and the quality of the evidence ranged from moderate to very low.

Use of Targeted Temperature Management After Out-of-hospital Cardiac Arrest: A Meta-Analysis of Randomized Controlled Trials

BackgroundIndividual randomized trials have yielded variable results regarding the benefits of targeted temperature management in patients encountering out-of-hospital cardiac arrest. This study aimed to systemically determine if targeted temperature management initiated after an out-of-hospital cardiac arrest was associated with improved outcomes. MethodsElectronic databases were searched for published randomized trials that compared targeted temperature management (core body temperature 32-34°C) vs control (core body temperature ≥36°C) after an out-of-hospital cardiac arrest. The main outcomes assessed were all-cause mortality and poor neurological outcome. ResultsSix trials with 1391 patients were included in the analysis. Compared with the control group, targeted temperature management was associated with a nonsignificant reduction in all-cause mortality (relative risk [RR] 0.90; 95% confidence interval [CI], 0.77-1.04; P = .15, I2 = 34%), which was similar among those with a shockable rhythm (RR 0.89; 95% CI, 0.74-1.08, P = .25, I2 = 46%). All-cause mortality was significantly reduced with targeted temperature management after exclusion of one trial that allowed for mild hypothermia in the control arm (RR 0.83; 95% CI, 0.71-0.96; P = .01, I2 = 0%). There was a nonsignificant reduction in poor neurological outcome with targeted temperature management compared with control (RR 0.87; 95% CI, 0.74-1.03, P = .10, I2 = 54%), which was similar among those with a shockable rhythm (RR 0.87; 95% CI, 0.70-1.07, P = .19, I2 = 63%). Poor neurological outcome was significantly reduced with targeted temperature management after exclusion of one trial that allowed for mild hypothermia in the control arm (RR 0.82; 95% CI, 0.70-0.95; P = .01, I2 = 19%). ConclusionTargeted temperature management initiated after successful resuscitation in patients who encountered an out-of-hospital cardiac arrest was associated with a nonsignificant reduction in mortality and poor neurological outcome. Lack of benefit was strongly influenced by inclusion of one study that used mild hypothermia in the control arm. These results indicate that only mild hypothermia may be needed to improve outcomes among patients presenting with an out-of-hospital cardiac arrest.

Temperature management after cardiac arrest.

Temperature management for patients comatose after cardiac arrest has been an integral component of postcardiac arrest care for the last decade. In this review, we present recent findings and discuss implications for future trials. The two largest trials on temperature management after cardiac arrest were recently presented. The first investigated prehospital induction of hypothermia using ice-cold intravenous saline in 1364 patients. The intervention gave a significant reduction in time from return of circulation to start of hypothermia and lower body temperature on admission to hospital. There was no difference in survival or neurological function between the study groups, but there were indications of possible harm in the group that received saline. The second trial investigated two actively controlled temperatures provided in intensive care units, randomizing 950 unconscious patients suffering out-of-hospital cardiac arrest of a presumed cardiac cause to targeted temperature management at 33 and 36°C. There was no difference in survival until end of trial or neurological function at 180 days. Prehospital hypothermia induced by cold crystalloid infusion does not benefit cardiac arrest patients. For patients treated in an intensive care unit targeting a temperature of 36°C provides similar results as targeting 33°C.

Survey of Brain Temperature Management in Patients with Traumatic Brain Injury in the Japan Neurotrauma Data Bank

The goal of this study was to evaluate the clinical characteristics and effects of brain temperature management in patients with severe traumatic brain injury (TBI). A total of 1091 patients were registered from the Japan Neurotrauma Data Bank Project 2009. Those with a Glasgow Coma Scale (GCS) score of 9 or more, a GCS score of 3, bilateral dilated pupils, or cardiopulmonary arrest on arrival were excluded. This left a total of 401 patients. Patients were classified into three groups: no temperature management, with no intervention for brain temperature (225 patients, 56.1%), intensive normothermia (129 patients, 32.2%), and hypothermia (47 patients, 11.7%). Patient age, GCS score, pupillary abnormality, Injury Severity Score (ISS), intracranial pressure (ICP) monitoring, and outcome according to CT classification (Traumatic Coma Data Bank classification) on admission were examined. Patients were significantly older in the no temperature management group (average age 61.5 years) compared with normothermia (53.6 years) and hypothermia (46.9 years). ICP monitoring was significantly decreased in 85.1% of patients with hypothermia, 42.6% with normothermia, and 14.7% in no temperature management group. Favorable outcome rate was significantly higher with hypothermia (52.4%) compared with normothermia (26.9%) and no temperature management (20.7%) with evacuated mass lesions in contrast to diffuse injury. Multivariate analysis in patients with evacuated mass lesions showed that GCS (≥6 pts), and hypothermia were independent factors related to a favorable outcome. Appropriate thermoregulation of the brain for individual patients with various types of TBI are important.

Temperature management in patients with acute neurological lesions: an Australian and New Zealand point prevalence study

Temperature management in patients with acute neurological lesions: an Australian and New Zealand point prevalence study

Temperature management for patients without brain injury in Australia and New Zealand ICUs: a point prevalence study

Our primary aim was to determine the frequency of use of pharmacological and physical cooling strategies in ICU patients in current Australian and New Zealand (ANZ) practice. These patients had sepsis and inflammation but did not have neurological injury or recent surgery. We also aimed to establish current indications for use of antipyretics in these patients, as well as information on the prevalence of fever and the methods to measure temperature.

Patient temperature management with Koala underbody convective air in port-access cardiac surgery

Patient temperature management with Koala underbody convective air in port-access cardiac surgery

Antegrade cerebral perfusion with mild hypothermia for aortic arch replacement: single centre experience in 245 consecutive patients

Objectives: This study investigates our clinical results after modification of perfusion technique for cardiopulmonary bypass as well as temperature management for patients undergoing aortic arch replacement.

Survey on intraoperative temperature management in Europe

Inadvertent perioperative hypothermia causes serious morbidity in surgical patients. However, recent reports suggest that patients might still be hypothermic after elective surgery. We thus surveyed intraoperative temperature monitoring and management practices in Europe. Postal survey of 801 representative hospitals from 17 European countries on the same day. The questions addressed the number of surgical procedures and type of anaesthesia performed, mode and site of temperature monitoring and method of patient warming. Mean and standard error of the mean or count and percentage were calculated. The t-test or contingency table analysis with the Fisher's exact test were used. Eight thousand and eighty-three surgical procedures were assessed from 316 responding hospitals (39.4%). Overall, patient temperature monitored in 19.4% and 38.5% of the patients were actively warmed. Under general anaesthesia, body temperature was monitored in 25% and during regional anaesthesia in 6%, P = 0.0005. Nasopharyngeal temperature was most often taken under general anaesthesia, while tympanic temperature was preferred during regional anaesthesia. Under general anaesthesia, 43% of patients were actively warmed as compared to 28% with regional anaesthesia, P = 0.0005. Forced-air warming was the method of choice for both general and regional anaesthesia. Intraoperative temperature monitoring is still uncommon and hence active patient warming is not a standard of care in Europe. Awareness of perioperative hypothermia is critical to its prevention, and thus temperature monitoring is a pre-requisite. The objective is to maintain normothermia in patients throughout surgery. A European practice guideline for perioperative patient temperature management is warranted.

Active Temperature Management in Patients Undergoing Endovascular Treatment for Cerebral Aneurysms

Active Temperature Management in Patients Undergoing Endovascular Treatment for Cerebral Aneurysms