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Rochat Negro T, Watchi M, Wozniak H, Pugin J, Quintard H. Diclofenac Sodium for Fever Control in Neurocritical Care: A Systematic Review. J Clin Med 2023; 12:jcm12103443. [PMID: 37240549 DOI: 10.3390/jcm12103443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/06/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Fever is extremely common in neurocritical care patients and is independently associated with a worse outcome. Non-steroidal anti-inflammatory drugs (NSAIDs) lower the hypothalamic set point temperature through the inhibition of prostaglandin E2 synthesis, and they constitute a second line of pharmacological treatment for temperature control. This systematic review aims to evaluate the effectiveness of DCF in reducing body temperature and its effects on brain parameters. METHODS A comprehensive search of several databases was run in November 2022 in Ovid EBM (Evidence Based Medicine) Reviews, Cochrane library, Ovid Medline and Scopus (1980 onward). The outcome of interest included DCF control of body temperature and its impact on cerebral parameters. RESULTS A total of 113 titles were identified as potentially relevant. Six articles met eligible criteria and were reviewed. DCF induce a reduction in body temperature (MD, 1.10 [0.72, 1.49], p < 0.00001), a slight decrease in ICP (MD, 2.22 [-0.25, 4.68] IC 95%; p < 0.08) as well as in CPP and MAP (MD, 5.58 [0.43, 10.74] IC 95%; p < 0.03). The significant heterogeneity and possibility of publication bias reduces the strength of the available evidence. CONCLUSIONS Diclofenac sodium is effective in reducing body temperature in patients with brain injury, but data in the literature are scarce and further studies are needed to evaluate the benefits of DCF.
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Affiliation(s)
| | | | - Hannah Wozniak
- Intensive Care, Hôpitaux Universitaires de Genève, 1205 Genève, Switzerland
| | - Jerome Pugin
- Intensive Care, Hôpitaux Universitaires de Genève, 1205 Genève, Switzerland
| | - Herve Quintard
- Intensive Care, Hôpitaux Universitaires de Genève, 1205 Genève, Switzerland
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Sung D, Risk BB, Wang KJ, Allen JW, Fleischer CC. Resting-State Brain Temperature: Dynamic Fluctuations in Brain Temperature and the Brain-Body Temperature Gradient. J Magn Reson Imaging 2023; 57:1222-1228. [PMID: 35904094 PMCID: PMC9884314 DOI: 10.1002/jmri.28376] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND While fluctuations in healthy brain temperature have been investigated over time periods of weeks to months, dynamics over shorter time periods are less clear. PURPOSE To identify physiological fluctuations in brain temperature in healthy volunteers over time scales of approximately 1 hour. STUDY TYPE Prospective. SUBJECTS A total of 30 healthy volunteers (15 female; 26 ± 4 years old). SEQUENCE AND FIELD STRENGTH 3 T; T1-weighted magnetization-prepared rapid gradient-echo (MPRAGE) and semi-localized by adiabatic selective refocusing (sLASER) single-voxel spectroscopy. ASSESSMENTS Brain temperature was calculated from the chemical shift difference between N-acetylaspartate and water. To evaluate within-scan repeatability of brain temperature and the brain-body temperature difference, 128 spectral transients were divided into two sets of 64-spectra. Between-scan repeatability was evaluated using two time periods, ~1-1.5 hours apart. STATISTICAL TESTS A hierarchical linear mixed model was used to calculate within-scan and between-scan correlations (Rw and Rb , respectively). Significance was determined at P ≤ .05. Values are reported as the mean ± standard deviation. RESULTS A significant difference in brain temperature was observed between scans (-0.4 °C) but body temperature was stable (P = .59). Brain temperature (37.9 ± 0.7 °C) was higher than body temperature (36.5 ± 0.5 °C) for all but one subject. Within-scan correlation was high for brain temperature (Rw = 0.95) and brain-body temperature differences (Rw = 0.96). Between scans, variability was high for both brain temperature (Rb = 0.30) and brain-body temperature differences (Rb = 0.41). DATA CONCLUSION Significant changes in brain temperature over time scales of ~1 hour were observed. High short-term repeatability suggests temperature changes appear to be due to physiology rather than measurement error. EVIDENCE LEVEL 2 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Dongsuk Sung
- Department of Radiology and Imaging Sciences, Emory University School of Medicine
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University
| | - Benjamin B. Risk
- Department of Biostatistics and Bioinformatics, Emory University
| | - Kelly J. Wang
- Department of Radiology and Imaging Sciences, Emory University School of Medicine
- Department of Neuroscience, Georgia Institute of Technology
| | - Jason W. Allen
- Department of Radiology and Imaging Sciences, Emory University School of Medicine
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University
| | - Candace C. Fleischer
- Department of Radiology and Imaging Sciences, Emory University School of Medicine
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University
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Bidirectional alterations in brain temperature profoundly modulate spatiotemporal neurovascular responses in-vivo. Commun Biol 2023; 6:185. [PMID: 36797344 PMCID: PMC9935519 DOI: 10.1038/s42003-023-04542-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/31/2023] [Indexed: 02/18/2023] Open
Abstract
Neurovascular coupling (NVC) is a mechanism that, amongst other known and latent critical functions, ensures activated brain regions are adequately supplied with oxygen and glucose. This biological phenomenon underpins non-invasive perfusion-related neuroimaging techniques and recent reports have implicated NVC impairment in several neurodegenerative disorders. Yet, much remains unknown regarding NVC in health and disease, and only recently has there been burgeoning recognition of a close interplay with brain thermodynamics. Accordingly, we developed a novel multi-modal approach to systematically modulate cortical temperature and interrogate the spatiotemporal dynamics of sensory-evoked NVC. We show that changes in cortical temperature profoundly and intricately modulate NVC, with low temperatures associated with diminished oxygen delivery, and high temperatures inducing a distinct vascular oscillation. These observations provide novel insights into the relationship between NVC and brain thermodynamics, with important implications for brain-temperature related therapies, functional biomarkers of elevated brain temperature, and in-vivo methods to study neurovascular coupling.
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Lee D, Ryu H, Jung E. Effect of Fever on the Clinical Outcomes of Traumatic Brain Injury by Age. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121860. [PMID: 36557064 PMCID: PMC9782200 DOI: 10.3390/medicina58121860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
Background and objective: Fever is a common symptom in patients with traumatic brain injury (TBI). However, the effect of fever on the clinical outcomes of patients with TBI is not well characterized. Our study aims to determine the impact of fever on the clinical outcomes of patients with TBI and test the interaction effect of fever on study outcomes according to age group. Materials and methods: Our retrospective study included adult patients with TBI who were transported to a level 1 trauma center by the emergency medical services (EMS) team. The main exposure is fever, defined as a body temperature of 38 °C or above, in the emergency department (ED). The primary outcome was mortality at hospital discharge. We conducted a multivariable logistic regression analysis to estimate the effect sizes of fever on study outcomes. We also conducted an interaction analysis between fever and age group on study outcomes. Results: In multivariable logistic regression analysis, patients with TBI who had fever showed no significant difference in mortality at hospital discharge (aOR, 95% CIs: 1.24 (0.57−3.02)). Fever significantly increased the mortality of elderly patients (>65 years) with TBI (1.39 (1.13−1.50)), whereas there was no significant effect on mortality in younger patients (18−64 years) (0.85 (0.51−1.54)). Conclusions: Fever was associated with mortality only in elderly patients with TBI.
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Affiliation(s)
- Dahae Lee
- Chonnam National University Hospital, Gwangju 61186, Republic of Korea
| | - Hyunho Ryu
- Chonnam National University Hospital, Gwangju 61186, Republic of Korea
- Chonnam National University, Gwangju 61186, Republic of Korea
| | - Eujene Jung
- Chonnam National University Hospital, Gwangju 61186, Republic of Korea
- Correspondence:
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Goryanin I, Ovchinnikov L, Vesnin S, Ivanov Y. Monitoring Protein Denaturation of Egg White Using Passive Microwave Radiometry (MWR). Diagnostics (Basel) 2022; 12:diagnostics12061498. [PMID: 35741308 PMCID: PMC9221703 DOI: 10.3390/diagnostics12061498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/08/2022] [Accepted: 06/15/2022] [Indexed: 11/16/2022] Open
Abstract
Passive microwave radiometry (MWR) is a measurement technique based on the detection of passive radiation in the microwave spectrum of different objects. When in equilibrium, this radiation is known to be proportional to the thermodynamic temperature of an emitting body. We hypothesize that living systems feature other mechanisms of emission that are based on protein unfolding and water rotational transitions. To understand the nature of these emissions, microwave radiometry was used in several in vitro experiments. In our study, we performed pilot measurements of microwave emissions from egg whites during denaturation induced by ethanol. Egg whites comprise 10% proteins, such as albumins, mucoproteins, and globulins. We observed a novel phenomenon: microwave emissions changed without a corresponding change in the water’s thermodynamic temperature. We also found striking differences between microwave emissions and thermodynamic temperature kinetics. Therefore, we hypothesize that these two processes are unrelated, contrary to what was thought before. It is known that some pathologies such as stroke or brain trauma feature increased microwave emissions. We hypothesize that this phenomenon originates from protein denaturation and is not related to the thermodynamic temperature. As such, our findings could explain the reason for the increase in microwave emissions after trauma and post mortem for the first time. These findings could be used for the development of novel diagnostics methods. The MWR method is inexpensive and does not require fluorescent or radioactive labels. It can be used in different areas of basic and applied pharmaceutical research, including in kinetics studies in biomedicine.
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Affiliation(s)
- Igor Goryanin
- Okinawa Institute of Science and Technology, Onna-son, Okinawa 904-049, Japan
- School of Informatics, University of Edinburgh, Edinburgh EH8 9YL, UK
- Institute Experimental and Theoretical Biophysics, 142290 Pushchino, Russia
- Correspondence:
| | - Lev Ovchinnikov
- Medical Microwave Radiometry (MMWR) LTD, Edinburgh EH10 5LZ, UK; (L.O.); (S.V.)
| | - Sergey Vesnin
- Medical Microwave Radiometry (MMWR) LTD, Edinburgh EH10 5LZ, UK; (L.O.); (S.V.)
| | - Yuri Ivanov
- Institute of Biomedical Chemistry, 10, Pogodinskaya st., 119121 Moscow, Russia;
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Abstract
OBJECTIVE Temperature abnormalities are recognized as a marker of human disease, and the therapeutic value of temperature is an attractive treatment target. The objective of this synthetic review is to summarize and critically appraise evidence for active temperature management in critically ill patients. DATA SOURCES We searched MEDLINE for publications relevant to body temperature management (including targeted temperature management and antipyretic therapy) in cardiac arrest, acute ischemic and hemorrhagic stroke, traumatic brain injury, and sepsis. Bibliographies of included articles were also searched to identify additional relevant studies. STUDY SELECTION English-language systematic reviews, meta-analyses, randomized trials, observational studies, and nonhuman data were reviewed, with a focus on the most recent randomized control trial evidence. DATA EXTRACTION Data regarding study methodology, patient population, temperature management strategy, and clinical outcomes were qualitatively assessed. DATA SYNTHESIS Temperature management is common in critically ill patients, and multiple large trials have been conducted to elucidate temperature targets, management strategies, and timing. The strongest data concerning the use of therapeutic hypothermia exist in comatose survivors of cardiac arrest, and recent trials suggest that appropriate postarrest temperature targets between 33°C and 37.5°C are reasonable. Targeted temperature management in other critical illnesses, including acute stroke, traumatic brain injury, and sepsis, has not shown benefit in large clinical trials. Likewise, trials of pharmacologic antipyretic therapy have not demonstrated improved outcomes, although national guidelines do recommend treatment of fever in patients with stroke and traumatic brain injury based on observational evidence associating fever with worse outcomes. CONCLUSIONS Body temperature management in critically ill patients remains an appealing therapy for several illnesses, and additional studies are needed to clarify management strategies and therapeutic pathways.
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Shevelev O, Petrova M, Smolensky A, Osmonov B, Toimatov S, Kharybina T, Karbainov S, Ovchinnikov L, Vesnin S, Tarakanov A, Goryanin I. Using medical microwave radiometry for brain temperature measurements. Drug Discov Today 2021; 27:881-889. [PMID: 34767961 DOI: 10.1016/j.drudis.2021.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 09/29/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022]
Abstract
Brain temperature (BT) is a crucial physiological parameter used to monitor cerebral status. Physical activities and traumatic brain injuries (TBI) can affect BT; therefore, non-invasive BT monitoring is an important way to gain insight into TBI, stroke, and wellbeing. The effects of BT on physical performance have been studied at length. When humans are under extreme conditions, most of the energy consumed is used to maintain the BT. In addition, measuring the BT is useful for early brain diagnostics. Passive microwave radiometry (MWR) measures the intrinsic radiation of tissues in the 1-4 GHz range. It was shown that non-invasive passive MWR technology can successfully measure BT and identify even small TBIs. Here, we review the potential applications of MWR for assessing BT.
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Affiliation(s)
- Oleg Shevelev
- People' Friendship University of Russia, Moscow, Russia; Federal Research and Clinical Centre for Resuscitation and Rehabilitation, Moscow, Russia
| | - Marina Petrova
- People' Friendship University of Russia, Moscow, Russia; Federal Research and Clinical Centre for Resuscitation and Rehabilitation, Moscow, Russia
| | - Andrey Smolensky
- Russian State University of Physical Culture, Sports, Youth and Tourism, Moscow, Russia
| | - Batyr Osmonov
- Educational - Scientifc Medical Center of Kyrgyz Medical Sate University, Bishkek, Kyrgyz Republic
| | | | - Tatyana Kharybina
- Library for Natural Sciences of the Russian Academy of Sciences, Moscow, Russia
| | | | | | - Sergey Vesnin
- Medical Microwave Radiometry Ltd, Edinburgh, UK; RTM Diagnostic LLC, Moscow, Russia; Bauman Moscow State Technical University, Moscow, Russia
| | | | - Igor Goryanin
- School of Informatics, University of Edinburgh, Edinburgh, UK; Institute Theoretical and Experimental Biophysics, Pushchino, Russia; Okinawa Institute Science and Technology, Okinawa, Japan.
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Lang SS, Kilbaugh T, Friess S, Sotardi S, Kim CT, Mazandi V, Zhang B, Storm PB, Heuer GG, Tucker A, Ampah SB, Griffis H, Raghupathi R, Huh JW. Trajectory of Long-Term Outcome in Severe Pediatric Diffuse Axonal Injury: An Exploratory Study. Front Neurol 2021; 12:704576. [PMID: 34594294 PMCID: PMC8477000 DOI: 10.3389/fneur.2021.704576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/15/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction: Pediatric severe traumatic brain injury (TBI) is one of the leading causes of disability and death. One of the classic pathoanatomic brain injury lesions following severe pediatric TBI is diffuse (multifocal) axonal injury (DAI). In this single institution study, our overarching goal was to describe the clinical characteristics and long-term outcome trajectory of severe pediatric TBI patients with DAI. Methods: Pediatric patients (<18 years of age) with severe TBI who had DAI were retrospectively reviewed. We evaluated the effect of age, sex, Glasgow Coma Scale (GCS) score, early fever ≥ 38.5°C during the first day post-injury, the extent of ICP-directed therapy needed with the Pediatric Intensity Level of Therapy (PILOT) score, and MRI within the first week following trauma and analyzed their association with outcome using the Glasgow Outcome Score—Extended (GOS-E) scale at discharge, 6 months, 1, 5, and 10 years following injury. Results: Fifty-six pediatric patients with severe traumatic DAI were analyzed. The majority of the patients were >5 years of age and male. There were 2 mortalities. At discharge, 56% (30/54) of the surviving patients had unfavorable outcome. Sixty five percent (35/54) of surviving children were followed up to 10 years post-injury, and 71% (25/35) of them made a favorable recovery. Early fever and extensive DAI on MRI were associated with worse long-term outcomes. Conclusion: We describe the long-term trajectory outcome of severe pediatric TBI patients with pure DAI. While this was a single institution study with a small sample size, the majority of the children survived. Over one-third of our surviving children were lost to follow-up. Of the surviving children who had follow-up for 10 years after injury, the majority of these children made a favorable recovery.
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Affiliation(s)
- Shih-Shan Lang
- Division of Neurosurgery, Department of Neurosurgery, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Todd Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Stuart Friess
- Department of Pediatrics, St. Louis Children's Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Susan Sotardi
- Department of Radiology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Chong Tae Kim
- Department of Physical Medicine and Rehabilitation and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Vanessa Mazandi
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Bingqing Zhang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Phillip B Storm
- Division of Neurosurgery, Department of Neurosurgery, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Gregory G Heuer
- Division of Neurosurgery, Department of Neurosurgery, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Alexander Tucker
- Division of Neurosurgery, Department of Neurosurgery, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Steve B Ampah
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Heather Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Ramesh Raghupathi
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Brain Temperature Influences Intracranial Pressure and Cerebral Perfusion Pressure After Traumatic Brain Injury: A CENTER-TBI Study. Neurocrit Care 2021; 35:651-661. [PMID: 34331210 PMCID: PMC8692292 DOI: 10.1007/s12028-021-01294-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 06/09/2021] [Indexed: 11/05/2022]
Abstract
Background After traumatic brain injury (TBI), fever is frequent. Brain temperature (BT), which is directly linked to body temperature, may influence brain physiology. Increased body and/or BT may cause secondary brain damage, with deleterious effects on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and outcome. Methods Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI), a prospective multicenter longitudinal study on TBI in Europe and Israel, includes a high resolution cohort of patients with data sampled at a high frequency (from 100 to 500 Hz). In this study, simultaneous BT, ICP, and CPP recordings were investigated. A mixed-effects linear model was used to examine the association between different BT levels and ICP. We additionally focused on changes in ICP and CPP during the episodes of BT changes (Δ BT ≥ 0.5 °C lasting from 15 min to 3 h) up or downward. The significance of ICP and CPP variations was estimated with the paired samples Wilcoxon test (also known as Wilcoxon signed-rank test). Results Twenty-one patients with 2,435 h of simultaneous BT and ICP monitoring were studied. All patients reached a BT of 38 °C and experienced at least one episode of ICP above 20 mm Hg. The linear mixed-effects model revealed an association between BT above 37.5 °C and higher ICP levels that was not confirmed for lower BT. We identified 149 episodes of BT changes. During BT elevations (n = 79) ICP increased, whereas CPP was reduced; opposite ICP and CPP variations occurred during episodes of BT reduction (n = 70). All these changes were of moderate clinical relevance (increase of ICP of 4.5 and CPP decrease of 7.5 mm Hg for BT rise, and ICP reduction of 1.7 and CPP elevation of 3.7 mm Hg during BT defervescence), even if statistically significant (p < 0.0001). It has to be noted, however, that a number of therapeutic interventions against intracranial hypertension was documented during those episodes. Conclusions Patients after TBI usually develop BT > 38 °C soon after the injury. BT may influence brain physiology, as reflected by ICP and CPP. An association between BT exceeding 37.5 °C and a higher ICP was identified but not confirmed for lower BT ranges. The relationship between BT, ICP, and CPP become clearer during rapid temperature changes. During episodes of temperature elevation, BT seems to have a significant impact on ICP and CPP.
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Asmar S, Bible L, Chehab M, Tang A, Khurrum M, Castanon L, Ditillo M, Douglas M, Joseph B. Traumatic brain injury induced temperature dysregulation: What is the role of β blockers? J Trauma Acute Care Surg 2021; 90:177-184. [PMID: 33332783 DOI: 10.1097/ta.0000000000002975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is associated with sympathetic discharge that leads to posttraumatic hyperthermia (PTH). Beta blockers (ββ) are known to counteract overactive sympathetic discharge. The aim of our study was to evaluate the effect of ββ on PTH in critically-ill TBI patients. METHODS We performed retrospective cohort analysis of the Medical Information Mart for Intensive Care database. We included all critically ill TBI patients with head Abbreviated Injury Scale (AIS) score of 3 or greater and other body region AIS score less than 2 who developed PTH (at least one febrile episode [T > 38.3°C] with negative microbiological cultures (blood, urine, and bronchoalveolar lavage). Patients on preinjury ββ were excluded. Patients were stratified into (ββ+) and (ββ-) groups. Propensity score matching was performed (1:1 ratio) controlling for patient demographics, injury parameters and other medications that influence temperature. Outcomes were the number of febrile episodes, maximum temperature, and the time interval between febrile episodes. Multivariate linear regression was performed. RESULTS We analyzed 4,286 critically ill TBI patients. A matched cohort of 1,544 patients was obtained: 772 ββ + (metoprolol, 60%; propranolol, 25%; and atenolol, 15%) and 772 ββ-. Mean age was 63.4 ± 15.4 years, median head AIS score of 3 (3-4), and median Injury Severity Score of 10 (9-16). Patients in the ββ+ group had a lower number of febrile episodes (8 episodes vs. 12 episodes; p = 0.003), lower median maximum temperature (38.0°C vs. 38.5°C; p = 0.025), and a longer median time between febrile episodes (3 hours vs. 1 hour; p = 0.013). On linear regression, propranolol was found to be superior in terms of reducing the number of febrile episodes and the maximum temperature. However, there was no significant difference between the three ββ in terms of reducing the time interval between febrile episodes (p = 0.582). CONCLUSION Beta blockers attenuate PTH by decreasing the frequency of febrile episodes, increasing the time interval between febrile episodes, and reducing the maximum rise in temperature. ββ may be a potential therapeutic modality in PTH. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Samer Asmar
- From the Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
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Oh JY, Jo K, Joo W, Yoo DS, Park H. Temperature Difference between Brain and Axilla according to Body Temperature in the Patient with Brain Injury. Korean J Neurotrauma 2020; 16:147-156. [PMID: 33163422 PMCID: PMC7607042 DOI: 10.13004/kjnt.2020.16.e40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/10/2020] [Accepted: 09/23/2020] [Indexed: 11/21/2022] Open
Abstract
Objective Commonly, brain temperature is estimated from measurements of body temperature. However, temperature difference between brain and body is still controversy. The objective of this study is to know temperature gradient between the brain and axilla according to body temperature in the patient with brain injury. Methods A total of 135 patients who had undergone cranial operation and had the thermal diffusion flow meter (TDF) insert were included in this analysis. The brain and axilla temperatures were measured simultaneously every 2 hours with TDF (2 kinds of devices: SABER 2000 and Hemedex) and a mercury thermometer. Saved data were divided into 3 groups according to axillary temperature. Three groups are hypothermia group (less than 36.4°C), normothermia group (between 36.5°C and 37.5°C), and hyperthermia group (more than 37.6°C). Results The temperature difference between brain temperature and axillary temperature was 0.93±0.50°C in all data pairs, whereas it was 1.28±0.56°C in hypothermia, 0.87±0.43°C in normothermia, and 0.71±0.41°C in hyperthermia. The temperature difference was statistically significant between the hypothermia and normothermia groups (p=0.000), but not between the normothermia and hyperthermia group (p=0.201). Conclusion This study show that brain temperature is significantly higher than the axillary temperature and hypothermia therapy is associated with large brain-axilla temperature gradients. If you do not have a special brain temperature measuring device, the results of this study will help predict brain temperature by measuring axillary temperature.
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Affiliation(s)
- Jong-Yang Oh
- Department of Neurosurgery, Saengsaeng Hospital, Bucheon, Korea
| | - Kwangwook Jo
- Department of Neurosurgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Wonil Joo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Haekwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
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Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Lateef S, Holman A, Carpenter J, James J. Can Therapeutic Hypothermia Diminish the Impact of Traumatic Brain Injury in Drosophila melanogaster? J Exp Neurosci 2019; 13:1179069518824852. [PMID: 30733630 PMCID: PMC6343440 DOI: 10.1177/1179069518824852] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/18/2018] [Indexed: 12/14/2022] Open
Abstract
Background/main objectives: No effective strategy exists to treat the well-recognized, devastating impact of traumatic brain injury (TBI) and chronic traumatic encephalopathy (CTE), which is the brain degeneration likely caused by repeated head trauma. The goals of this project were (1) to study the effects of single and recurrent TBI (rTBI) on Drosophila melanogaster’s (a) life span, (b) response to sedatives, and (c) behavioral responses to light and gravity and (2) to determine whether therapeutic hypothermia can mitigate the deleterious effects of TBI. Methods: Five experimental groups were created: (1) control, (2) single TBI or concussion; (3) concussion + hypothermia, (4) rTBI, and (5) rTBI + hypothermia. A “high-impact trauma” (HIT) device was built, which used a spring-based mechanism to propel flies against the wall of a vial, causing mechanical damage to the brain. Hypothermia groups were cooled to 15°C for 3 minutes. Group differences were analyzed with chi-square tests for the categorical variables and with ANOVA tests for the continuous variables. Results: Survival curve analysis showed that rTBI can decrease Drosophila lifespan and hypothermia diminished this impact. Average sedation time for control vs concussion vs concussion + hypothermia was 78 vs 52 vs 61 seconds (P < .0001). Similarly, rTBI vs rTBI/hypothermia groups took 43 vs 59 seconds (P < .0001). Concussed flies preferred dark environments compared with control flies (risk ratio 3.3, P < .01) while flies who were concussed and cooled had a risk ratio of 2.7 (P < .01). Flies with rTBI were almost 4 times likely to prefer the dark environment but only 3 times as likely if they were cooled, compared with controls. Geotaxis was significantly affected by rTBI only and yet less so if rTBI flies were cooled. Conclusions: Hypothermia successfully mitigated many deleterious effects of single TBI and rTBI in Drosophila and may represent a promising breakthrough in the treatment of human TBI.
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Affiliation(s)
- Shan Lateef
- Jefferson Underclassman Multidisciplinary Laboratory (JUMP Lab), Thomas Jefferson High School for Science and Technology, Alexandria, VA, USA
| | - Aubrie Holman
- Jefferson Underclassman Multidisciplinary Laboratory (JUMP Lab), Thomas Jefferson High School for Science and Technology, Alexandria, VA, USA
| | - Jessica Carpenter
- Children's National Health System and School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Jennifer James
- Jefferson Underclassman Multidisciplinary Laboratory (JUMP Lab), Thomas Jefferson High School for Science and Technology, Alexandria, VA, USA
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Nyanzu M, Siaw-Debrah F, Ni H, Xu Z, Wang H, Lin X, Zhuge Q, Huang L. Improving on Laboratory Traumatic Brain Injury Models to Achieve Better Results. Int J Med Sci 2017; 14:494-505. [PMID: 28539826 PMCID: PMC5441042 DOI: 10.7150/ijms.18075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/31/2017] [Indexed: 11/30/2022] Open
Abstract
Experimental modeling of traumatic brain injury (TBI) in animals has identified several potential means and interventions that might have beneficial applications for treating traumatic brain injury clinically. Several of these interventions have been applied and tried with humans that are at different phases of testing (completed, prematurely terminated and others in progress). The promising results achieved in the laboratory with animal models have not been replicated with human trails as expected. This review will highlight some insights and significance attained via laboratory animal modeling of TBI as well as factors that require incorporation into the experimental studies that could help in translating results from laboratory to the bedside. Major progress has been made due to laboratory studies; in explaining the mechanisms as well as pathophysiological features of brain damage after TBI. Attempts to intervene in the cascade of events occurring after TBI all rely heavily on the knowledge from basic laboratory investigations. In looking to discover treatment, this review will endeavor to sight and state some central discrepancies between laboratory models and clinical scenarios.
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Affiliation(s)
- Mark Nyanzu
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, First Affiliated Hospital, Wenzhou Medical University, Wenzhou 325000, China.,Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Felix Siaw-Debrah
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, First Affiliated Hospital, Wenzhou Medical University, Wenzhou 325000, China.,Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Haoqi Ni
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, First Affiliated Hospital, Wenzhou Medical University, Wenzhou 325000, China.,Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Zhu Xu
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, First Affiliated Hospital, Wenzhou Medical University, Wenzhou 325000, China.,Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Hua Wang
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, First Affiliated Hospital, Wenzhou Medical University, Wenzhou 325000, China.,Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Xiao Lin
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, First Affiliated Hospital, Wenzhou Medical University, Wenzhou 325000, China.,Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Qichuan Zhuge
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, First Affiliated Hospital, Wenzhou Medical University, Wenzhou 325000, China.,Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Lijie Huang
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, First Affiliated Hospital, Wenzhou Medical University, Wenzhou 325000, China.,Department of Neurosurgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
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15
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Chiumello D, Gotti M, Vergani G. Paracetamol in fever in critically ill patients-an update. J Crit Care 2016; 38:245-252. [PMID: 27992852 DOI: 10.1016/j.jcrc.2016.10.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 09/20/2016] [Accepted: 10/31/2016] [Indexed: 11/26/2022]
Abstract
Fever, which is arbitrary defined as an increase in body temperature above 38.3°C, can affect up to 90% of patients admitted in intensive care unit. Induction of fever is mediated by the release of pyrogenic cytokines (tumor necrosis factor α, interleukin 1, interleukin 6, and interferons). Fever is associated with increased length of stay in intensive care unit and with a worse outcome in some subgroups of patients (mainly neurocritically ill patients). Although fever can increase oxygen consumption in unstable patients, on the contrary, it can activate physiologic systems that are involved in pathogens clearance. Treatments to reduce fever include the use of antipyretics. Thus, the reduction of fever might reduce the ability to develop an efficient host response. This balance, between harms and benefits, has to be taken into account every time we decide to treat or not to treat fever in a given patient. Among the antipyretics, paracetamol is one of the most common used. Paracetamol is a synthetic, nonopioid, centrally acting analgesic, and antipyretic drug. Its antipyretic effect occurs because it inhibits cyclooxygenase-3 and the prostaglandin synthesis, within the central nervous system, resetting the hypothalamic heat-regulation center. In this clinical review, we will summarize the use of paracetamol as antipyretic in critically ill patients (sepsis, trauma, neurological, and medical).
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Affiliation(s)
- D Chiumello
- Dipartimento di Emergenza-Urgenza, ASST Santi Paolo e Carlo, Milan, Italy; Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy.
| | - M Gotti
- Dipartimento di Emergenza-Urgenza, ASST Santi Paolo e Carlo, Milan, Italy
| | - G Vergani
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
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16
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Laux C, Guanci MM, Figueroa SA, Francis KE, Livesay SL, Mathiesen C. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2016; 6:52-6. [PMID: 26866958 DOI: 10.1089/ther.2016.29009.mkb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Chris Laux
- 2 Harborview Medical Center , Seattle, Washington
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17
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Radomski M, Zettervall S, Schroeder ME, Messing J, Dunne J, Sarani B. Critical Care for the Patient With Multiple Trauma. J Intensive Care Med 2015; 31:307-18. [PMID: 25673631 DOI: 10.1177/0885066615571895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 01/12/2015] [Indexed: 02/06/2023]
Abstract
Trauma remains the leading cause of death worldwide and the leading cause of death in those less than 44 years old in the United States. Admission to a verified trauma center has been shown to decrease mortality following a major injury. This decrease in mortality has been a direct result of improvements in the initial evaluation and resuscitation from injury as well as continued advances in critical care. As such, it is vital that intensive care practitioners be familiar with various types of injuries and their associated treatment strategies as well as their potential complications in order to minimize the morbidity and mortality frequently seen in this patient population.
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Affiliation(s)
- Michal Radomski
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Sara Zettervall
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Mary Elizabeth Schroeder
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Jonathan Messing
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - James Dunne
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Babak Sarani
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
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18
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Liu YH, Shang ZDE, Chen C, Lu N, Liu QF, Liu M, Yan J. 'Cool and quiet' therapy for malignant hyperthermia following severe traumatic brain injury: A preliminary clinical approach. Exp Ther Med 2014; 9:464-468. [PMID: 25574217 PMCID: PMC4280981 DOI: 10.3892/etm.2014.2130] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 10/21/2014] [Indexed: 12/16/2022] Open
Abstract
Malignant hyperthermia increases mortality and disability in patients with brain trauma. A clinical treatment for malignant hyperthermia following severe traumatic brain injury, termed ‘cool and quiet’ therapy by the authors of the current study, was investigated. Between June 2003 and June 2013, 110 consecutive patients with malignant hyperthermia following severe traumatic brain injury were treated using mild hypothermia (35–36°C) associated with small doses of sedative and muscle relaxant. Physiological parameters and intracranial pressure were monitored, and the patients slowly rewarmed following the maintenance of mild hypothermia for 3–12 days. Consecutive patients who had undergone normothermia therapy were retrospectively analyzed as the control. In the mild hypothermia group, the recovery rate was 54.5%, the mortality rate was 22.7%, and the severe and mild disability rates were 11.8 and 10.9%, respectively. The mortality rate of the patients, particularly that of patients with a Glasgow Coma Scale (GCS) score of between 3 and 5 differed significantly between the hypothermia group and the normothermia group (P<0.05). The mortality of patients with a GCS score of between 6 and 8 was not significantly different between the two groups (P> 0.05). The therapy using mild hypothermia with a combination of sedative and muscle relaxant was beneficial in decreasing the mortality of patients with malignant hyperthermia following severe traumatic brain injury, particularly in patients with a GCS score within the range 3–5 on admission. The therapy was found to be safe, effective and convenient. However, rigorous clinical trials are required to provide evidence of the effectiveness of ‘cool and quiet’ therapy for hyperthermia.
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Affiliation(s)
- Yu-He Liu
- Department of Neurosurgery, The 88th Hospital of PLA, Taian, Shandong 271000, P.R. China
| | - Zhen-DE Shang
- Department of Neurosurgery, The 88th Hospital of PLA, Taian, Shandong 271000, P.R. China
| | - Chao Chen
- Department of Neurosurgery, The 88th Hospital of PLA, Taian, Shandong 271000, P.R. China
| | - Nan Lu
- Department of Neurosurgery, The 88th Hospital of PLA, Taian, Shandong 271000, P.R. China
| | - Qi-Feng Liu
- Department of Neurosurgery, The 88th Hospital of PLA, Taian, Shandong 271000, P.R. China
| | - Ming Liu
- Department of Neurosurgery, The 88th Hospital of PLA, Taian, Shandong 271000, P.R. China
| | - Jing Yan
- Department of Neurosurgery, The 88th Hospital of PLA, Taian, Shandong 271000, P.R. China
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Abstract
PURPOSE OF REVIEW Fever is common in the ICU among patients with severe brain injury. Fever has been consistently shown to exacerbate brain injuries in animal models and has been consistently associated with poor outcome in human studies. However, whether fever control improves outcome and the ideal means of fever control remain unknown. This review will address recent literature on the impact of fever on severe brain injury and on interventions to maintain normothermia. RECENT FINDINGS Current guidelines generally recommend maintenance of normothermia after brain injury but have scant recommendations on methods to do this. Observational trials have continued to demonstrate the association between fever and poor outcome after severe brain injury. Recent trials have shown the efficacy of more aggressive approaches to fever reduction, whereas a large randomized trial showed the relative ineffectiveness of acetaminophen alone for fever control. Several studies have also described the impact of fever and of fever control on brain physiology. SUMMARY The value of therapeutic normothermia in the neurocritical care unit (NCCU) is increasingly accepted, yet prospective trials that demonstrate a functional benefit to patients are lacking.
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Wang HC, Sun CF, Chen H, Chen MS, Shen G, Ma YB, Wang BD. Where are we in the modelling of traumatic brain injury? Models complicated by secondary brain insults. Brain Inj 2014; 28:1491-503. [PMID: 25111457 DOI: 10.3109/02699052.2014.943288] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Hong-Cai Wang
- Department of Neurosurgery, Li Hui Li Hospital of Medical Centre of Ningbo
NingboPR China
| | - Cheng-Feng Sun
- Department of Neurosurgery, Li Hui Li Hospital of Medical Centre of Ningbo
NingboPR China
| | - Hai Chen
- Department of Neurosurgery, Li Hui Li Hospital of Medical Centre of Ningbo
NingboPR China
| | - Mao-Song Chen
- Department of Neurosurgery, Li Hui Li Hospital of Medical Centre of Ningbo
NingboPR China
| | - Gang Shen
- Department of Neurosurgery, Li Hui Li Hospital of Medical Centre of Ningbo
NingboPR China
| | - Yan-Bin Ma
- Department of Neurosurgery, NO.3 People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine
ShanghaiPR China
| | - Bo-Ding Wang
- Department of Neurosurgery, Li Hui Li Hospital of Medical Centre of Ningbo
NingboPR China
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21
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Laptook AR, McDonald SA, Shankaran S, Stephens BE, Vohr BR, Guillet R, Higgins RD, Das A. Elevated temperature and 6- to 7-year outcome of neonatal encephalopathy. Ann Neurol 2013; 73:520-8. [PMID: 23595408 DOI: 10.1002/ana.23843] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 11/20/2012] [Accepted: 11/30/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVE A study was undertaken to determine whether higher temperature after hypoxia-ischemia is associated with death or intelligence quotient (IQ)<70 at 6 to 7 years among infants treated with intensive care without hypothermia. METHODS Control infants (noncooled, n=106) of the National Institute of Child Health and Human Development Neonatal Research Network hypothermia trial had serial esophageal and skin temperatures over 72 hours. Each infant's temperature was ranked to derive an average of the upper and lower quartile, and median of each site. Temperatures were used in logistic regressions to determine adjusted associations with death or IQ<70 at 6 to 7 years. Secondary outcomes were death, IQ<70, and moderate/severe cerebral palsy (CP). IQ and motor function were assessed with Wechsler Scales for Children and Gross Motor Function Classification System. Results are odds ratio (OR; per degree Celsius increment within the quartile or median) and 95% confidence interval (CI). RESULTS Primary outcome was available for 89 infants. At 6 to 7 years, death or IQ<70 occurred in 54 infants (37 deaths, 17 survivors with IQ<70) and moderate/severe CP in 15 infants. Death or IQ<70 was associated with the upper quartile average of esophageal (OR=7.3, 95% CI=2.0-26.3) and skin temperature (OR=3.5, 95% CI=1.2-10.4). CP was associated with the upper quartile average of esophageal (OR=12.5, 95% CI=1.02-155) and skin temperature (OR=10.3, 95% CI=1.3-80.2). INTERPRETATION Among noncooled infants of a randomized trial, elevated temperatures during the first postnatal days are associated with increased odds of a worse outcome at 6 to 7 years.
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Affiliation(s)
- Abbot R Laptook
- Alpert Medical School of Brown University and Women & Infants Hospital of Rhode Island, Providence, RI
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22
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Springborg JB, Springborg KK, Romner B. First Clinical Experience with Intranasal Cooling for Hyperthermia in Brain-Injured Patients. Neurocrit Care 2013; 18:400-5. [DOI: 10.1007/s12028-012-9806-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Brain temperature: physiology and pathophysiology after brain injury. Anesthesiol Res Pract 2012; 2012:989487. [PMID: 23326261 PMCID: PMC3541556 DOI: 10.1155/2012/989487] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 11/09/2012] [Accepted: 12/12/2012] [Indexed: 12/02/2022] Open
Abstract
The regulation of brain temperature is largely dependent on the metabolic activity of brain tissue and remains complex. In intensive care clinical practice, the continuous monitoring of core temperature in patients with brain injury is currently highly recommended. After major brain injury, brain temperature is often higher than and can vary independently of systemic temperature. It has been shown that in cases of brain injury, the brain is extremely sensitive and vulnerable to small variations in temperature. The prevention of fever has been proposed as a therapeutic tool to limit neuronal injury. However, temperature control after traumatic brain injury, subarachnoid hemorrhage, or stroke can be challenging. Furthermore, fever may also have beneficial effects, especially in cases involving infections. While therapeutic hypothermia has shown beneficial effects in animal models, its use is still debated in clinical practice. This paper aims to describe the physiology and pathophysiology of changes in brain temperature after brain injury and to study the effects of controlling brain temperature after such injury.
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Li J, Jiang JY. Chinese Head Trauma Data Bank: effect of hyperthermia on the outcome of acute head trauma patients. J Neurotrauma 2012; 29:96-100. [PMID: 22026424 PMCID: PMC3253306 DOI: 10.1089/neu.2011.1753] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Hyperthermia may accentuate the detrimental consequences of brain injury and worsen the outcome of patients with acute head trauma, especially severe traumatic brain injury (TBI). We explored the effect of different magnitudes and durations of hyperthermia in the first 3 days after injury on the outcome of 7145 patients with acute head trauma, including 1626 with severe TBI. The differences in mortality and unfavorable outcome between the normothermia group, mild fever group, moderate fever group, and high fever group were statistically significant (p<0.001). The mortality and unfavorable outcome of severe TBI patients in the groups also differed significantly (p<0.001). The mortality and unfavorable outcome of patients with 1 day, 2 days, and 3 days of high fever were significantly increased (p<0.01). Our data strongly indicate that both degree and duration of early post-trauma hyperthermia are closely correlated with the outcome of acute TBI patients, especially severely injured ones, which indicates that hyperthermia may play a detrimental role in the delayed mechanisms of damage after acute TBI. Prevention of early hyperthermia after acute head trauma is therefore essential to the management of TBI patients.
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Affiliation(s)
- Jin Li
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
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25
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Advancing critical care: joint combat casualty research team and joint theater trauma system. AACN Adv Crit Care 2011; 21:260-76; quiz 278. [PMID: 20683227 DOI: 10.1097/nci.0b013e3181e67385] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Despite the severity and complexity of injuries, survival rates among combat casualties are equal to or better than those from civilian trauma. This article summarizes the evidence regarding innovations from the battlefield that contribute to these extraordinary survival rates, including preventing hemorrhage with the use of tourniquets and hemostatic dressings, damage control resuscitation, and the rapid evacuation of casualties via MEDEVAC and the US Air Force Critical Care Air Transport Teams. Care in the air for critically injured casualties with pulmonary injuries and traumatic brain injury is discussed to demonstrate the unique considerations required to ensure safe en route care. Innovations being studied to decrease sequelae associated with complex orthopedic and extremity trauma are also presented. The role and contributions of the Joint Combat Casualty Research Team and the Joint Theater Trauma System are also discussed.
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Abstract
AIMS The specific aims were to (1) define fever from the nurse's perspective; (2) describe fever management decision-making by nurses and (3) describe barriers to evidence-based practice across various settings. BACKGROUND Publication of practice guidelines, which address fever management, has not yielded improvements in nursing care. This may be related to differences in ways nurses define and approach fever. METHOD The collective case study approach was used to guide the process of data collection and analysis. Data were collected during 2006-7. Transcripts were coded using the constant comparative method until themes were identified. Cross-case comparison was conducted. The nursing process was used as an analytical filter for refinement and presentation of the findings. FINDINGS Nurses across settings defined fever as a (single) elevated temperature that exceeded some established protocol. Regardless of practice setting, interventions chosen by nurses were frequently based on trial and error or individual conventions -'what works'- rather than evidence-based practice. Some nurses' accounts indicated use of interventions that were clearly contraindicated by the literature. Participants working on dedicated neuroscience units articulated specific differences in patient care more than those working on mixed units. CONCLUSIONS By defining a set temperature for intervention, protocols may serve as a barrier to critical clinical judgment. We recommend that protocols be developed in an interdisciplinary manner to foster local adaptation of best practices. This could further best practice by encouraging individual nurses to think of protocols not as a recipe, but rather as a guide when individualizing patient care. There is value of specialty knowledge in narrowing the translational gap, offering institutions evidence for planning and structuring the organization of care.
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Affiliation(s)
- Hilaire J Thompson
- Biobehavioral Nursing and Health Systems, The University of Washington, Seattle, Washington, USA.
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Sacho RH, Vail A, Rainey T, King AT, Childs C. The effect of spontaneous alterations in brain temperature on outcome: a prospective observational cohort study in patients with severe traumatic brain injury. J Neurotrauma 2010; 27:2157-64. [PMID: 20822465 DOI: 10.1089/neu.2010.1384] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
There are few prospective studies reporting the effect of spontaneous temperature changes on outcome after severe traumatic brain injury (TBI). Where studies have been conducted, results are based on systemic rather than brain temperature per se. However, body temperature is not a reliable surrogate for brain temperature. Consequently, the effect of brain temperature changes on outcome in the acute phase after TBI is not clear. Continuous intraparenchymal brain temperature was measured in consecutive admissions of severe TBI patients during the course of the first 5 days of admission to the intensive care unit (ICU). Patients received minimal temperature altering therapy during their ICU stay. Logistic regression was used to explore the relationship between the initial, the 24-h mean, and the 48-h mean brain temperature with outcome for mortality at 30 days and outcome at 3 months. Multifactorial analysis was performed to account for potential confounders. At the 24-h time point, brain temperature within the range of 36.5°C to 38°C was associated with a lower probability of death (10-20%). Brain temperature outside of this range was associated with a higher probability of death and poor 3-month neurological outcome. After adjusting for other predictors of outcome, low brain temperature was independently associated with a worse outcome. Lower brain temperatures (below 37°C) are independently associated with a higher mortality rate after severe TBI. The results suggest that, contrary to current opinion, temperatures within the normal to moderate fever range during the acute post-TBI period do not impose an additional risk for a poor outcome after severe TBI.
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Affiliation(s)
- Raphael H Sacho
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, United Kingdom.
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29
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Finkelstein RA, Alam HB. Induced hypothermia for trauma: current research and practice. J Intensive Care Med 2010; 25:205-26. [PMID: 20444735 DOI: 10.1177/0885066610366919] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Induction of hypothermia with the goal of providing therapeutic benefit has been accepted for use in the clinical setting of adult cardiac arrest and neonatal hypoxic-ischemic encephalopathy (HIE). However, its potential as a treatment in trauma is not as well defined. This review discusses potential benefits and complications of induced hypothermia (IH) with emphasis on the current state of knowledge and practice in various types of trauma. There is excellent preclinical research showing that in cases of penetrating trauma with cardiac arrest, inducing hypothermia to 10 degrees C using cardiopulmonary bypass (CPB) could possibly save those otherwise likely to die without causing neurologic sequelae. A human trial of this intervention is about to get underway. Preclinical studies suggest that inducing hypothermia may be useful to delay cardiac arrest in penetrating trauma victims who are hypotensive. There is potential for IH to be used in cases of blunt trauma, but it has not been well studied. In the case of traumatic brain injury (TBI), clinical trials have shown conflicting results, despite almost uniform efficacy seen in preclinical experiments. Major studies are analyzed and ways to standardize its use and optimize future clinical trials are discussed. More preclinical and clinical research is needed to better define whether there could be a role for IH in the case of spinal cord injuries.
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Affiliation(s)
- Robert A Finkelstein
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
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Dietrich WD, Bramlett HM. The evidence for hypothermia as a neuroprotectant in traumatic brain injury. Neurotherapeutics 2010; 7:43-50. [PMID: 20129496 PMCID: PMC2819078 DOI: 10.1016/j.nurt.2009.10.015] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 10/21/2009] [Indexed: 11/30/2022] Open
Abstract
This article reviews published experimental and clinical evidence for the benefits of modest hypothermia in the treatment of traumatic brain injury (TBI). Therapeutic hypothermia has been reported to improve outcome in several animal models of CNS injury and has been successfully translated to specific patient populations. A PubMed search for hypothermia and TBI was conducted, and important papers were selected for review. The research summarized was conducted at major academic institutions throughout the world. Experimental studies have emphasized that hypothermia can affect multiple pathophysiological mechanisms thought to participate in the detrimental consequences of TBI. Published data from several relevant clinical trials on the use of hypothermia in severely injured TBI patients are also reviewed. The consequences of mild to moderate levels of hypothermia introduced by different strategies to the head-injured patient for variable periods of time are discussed. Both experimental and clinical data support the beneficial effects of modest hypothermia following TBI in specific patient populations. Following on such single-institution studies, positive findings from multicenter TBI trials will be required before this experimental treatment can be considered standard of care.
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Affiliation(s)
- W Dalton Dietrich
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida 33136, USA.
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Broessner G, Beer R, Lackner P, Helbok R, Fischer M, Pfausler B, Rhorer J, Küppers-Tiedt L, Schneider D, Schmutzhard E. Prophylactic, Endovascularly Based, Long-Term Normothermia in ICU Patients With Severe Cerebrovascular Disease. Stroke 2009; 40:e657-65. [DOI: 10.1161/strokeaha.109.557652] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Gregor Broessner
- From the Department of Neurology (G.B., R.B., P.L., R.H., M.F., B.P., E.S.), Neurologic Intensive Care Unit, Innsbruck Medical University, Innsbruck, Austria; Statistics Collaborative Inc (J.R.), Washington, DC; and the Department of Neurology (L.K.-T., D.S.), Neurologic Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Ronny Beer
- From the Department of Neurology (G.B., R.B., P.L., R.H., M.F., B.P., E.S.), Neurologic Intensive Care Unit, Innsbruck Medical University, Innsbruck, Austria; Statistics Collaborative Inc (J.R.), Washington, DC; and the Department of Neurology (L.K.-T., D.S.), Neurologic Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Peter Lackner
- From the Department of Neurology (G.B., R.B., P.L., R.H., M.F., B.P., E.S.), Neurologic Intensive Care Unit, Innsbruck Medical University, Innsbruck, Austria; Statistics Collaborative Inc (J.R.), Washington, DC; and the Department of Neurology (L.K.-T., D.S.), Neurologic Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Raimund Helbok
- From the Department of Neurology (G.B., R.B., P.L., R.H., M.F., B.P., E.S.), Neurologic Intensive Care Unit, Innsbruck Medical University, Innsbruck, Austria; Statistics Collaborative Inc (J.R.), Washington, DC; and the Department of Neurology (L.K.-T., D.S.), Neurologic Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Marlene Fischer
- From the Department of Neurology (G.B., R.B., P.L., R.H., M.F., B.P., E.S.), Neurologic Intensive Care Unit, Innsbruck Medical University, Innsbruck, Austria; Statistics Collaborative Inc (J.R.), Washington, DC; and the Department of Neurology (L.K.-T., D.S.), Neurologic Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Bettina Pfausler
- From the Department of Neurology (G.B., R.B., P.L., R.H., M.F., B.P., E.S.), Neurologic Intensive Care Unit, Innsbruck Medical University, Innsbruck, Austria; Statistics Collaborative Inc (J.R.), Washington, DC; and the Department of Neurology (L.K.-T., D.S.), Neurologic Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Janelle Rhorer
- From the Department of Neurology (G.B., R.B., P.L., R.H., M.F., B.P., E.S.), Neurologic Intensive Care Unit, Innsbruck Medical University, Innsbruck, Austria; Statistics Collaborative Inc (J.R.), Washington, DC; and the Department of Neurology (L.K.-T., D.S.), Neurologic Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Lea Küppers-Tiedt
- From the Department of Neurology (G.B., R.B., P.L., R.H., M.F., B.P., E.S.), Neurologic Intensive Care Unit, Innsbruck Medical University, Innsbruck, Austria; Statistics Collaborative Inc (J.R.), Washington, DC; and the Department of Neurology (L.K.-T., D.S.), Neurologic Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Dietmar Schneider
- From the Department of Neurology (G.B., R.B., P.L., R.H., M.F., B.P., E.S.), Neurologic Intensive Care Unit, Innsbruck Medical University, Innsbruck, Austria; Statistics Collaborative Inc (J.R.), Washington, DC; and the Department of Neurology (L.K.-T., D.S.), Neurologic Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Erich Schmutzhard
- From the Department of Neurology (G.B., R.B., P.L., R.H., M.F., B.P., E.S.), Neurologic Intensive Care Unit, Innsbruck Medical University, Innsbruck, Austria; Statistics Collaborative Inc (J.R.), Washington, DC; and the Department of Neurology (L.K.-T., D.S.), Neurologic Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
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Abstract
PURPOSE OF REVIEW Fever in the neurocritical care setting is very common and has a negative impact on outcome of all disease types. Recent advances have made eliminating fever and maintaining normothermia feasible. However, important questions regarding indications and timing remain. The purpose of this review is to analyze the data surrounding the impact of fever across a range of neurologic injuries to better understand the optimal timing and duration of fever control. RECENT FINDINGS Meta-analyses have demonstrated that fever at onset and in the acute setting after ischemic brain injury, intracerebral hemorrhage, and cardiac arrest have a negative impact on morbidity and mortality. There are data to support that the impact of fever is sustained for longer durations after subarachnoid hemorrhage and traumatic brain injury. However, there are currently no prospective randomized trials demonstrating the benefit of fever control in these patient populations. SUMMARY The negative impact of fever after neurologic injury is well understood. Prospective randomized trials are needed to determine whether the beneficial impact of secondary injury prevention is outweighed by the potential infectious risk of prolonged fever control.
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Abstract
Fever in the neurocritical care setting is common and has a negative impact on outcome of all disease types. Meta-analyses have demonstrated that fever at onset and in the acute setting after ischemic brain injury, intracerebral hemorrhage, and cardiac arrest has a negative impact on morbidity and mortality. Data support that the impact of fever is sustained for longer durations after subarachnoid hemorrhage and traumatic brain injury. Recent advances have made eliminating fever and maintaining normothermia feasible. However, there are no prospective randomized trials demonstrating the benefit of fever control in these patient populations, and important questions regarding indications and timing remain. The purpose of this review is to analyze the data surrounding the impact of fever across a range of neurologic injuries to better understand the optimal timing and duration of fever control. Prospective randomized trials are needed to determine whether the beneficial impact of secondary injury prevention is outweighed by the potential risks of prolonged fever control.
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Badjatia N. FEVER MANAGEMENT. Continuum (Minneap Minn) 2009. [DOI: 10.1212/01.con.0000348820.19372.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Olson DM, Kelly AP, Washam NC, Thoyre SM. Critical care nurses' workload estimates for managing patients during induced hypothermia. Nurs Crit Care 2009; 13:305-9. [PMID: 19128314 DOI: 10.1111/j.1478-5153.2008.00298.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The purpose of this study was to provide an initial foundation for exploring how induced hypothermia impacts nursing workload in an intensive care unit setting. METHODS This descriptive study used a questionnaire to obtain input from critical care nurses. RESULTS The results represent 107 returned surveys from 120 surveys distributed to seven different critical care units. Nurses estimate a mean time of 9.27 min (95% CI = 5.63-12.92 min) per shift for each intervention. Nurses indicate that they typically consider employing over 10 interventions to reduce temperature or induce hypothermia (95% CI = 9.67-10.81). CONCLUSIONS Nurses are open to using a variety of different interventions to manage temperature in critically ill patients. The time required to complete any one intervention varies significantly, but the combination of interventions most certainly has a significant impact on the workload for bedside nurses.
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Affiliation(s)
- DaiWai M Olson
- Medicine/Neurology, Duke University Medical Center, Durham, NC 27710, USA.
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Naidech AM, Bendok BR, Bernstein RA, Alberts MJ, Batjer HH, Watts CM, Bleck TP. Fever burden and functional recovery after subarachnoid hemorrhage. Neurosurgery 2009; 63:212-7; discussion 217-8. [PMID: 18797350 DOI: 10.1227/01.neu.0000320453.61270.0f] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Fever is associated with worse outcome after subarachnoid hemorrhage, but there are few prospective data to quantify this relationship. METHODS We prospectively enrolled consecutive aneurysmal or cryptogenic subarachnoid hemorrhage patients and recorded the highest core temperature each calendar day for Day 0 (the day of hemorrhage) through Day 13. Fever burden was defined as the daily highest core temperature minus 100.4 degrees F, summed from admission through Day 13 (temperatures <100.4 degrees F did not contribute to or subtract from fever burden). Outcomes were assessed at 14 days or at the time of hospital discharge with the National Institutes of Health Stroke Scale and modified Rankin Scale, and at 28 days and 3 months with the modified Rankin Scale. Improvement was analyzed with repeated measures analysis of variance. RESULTS We prospectively enrolled 94 patients. From 14 days to 28 days to 3 months, functional improvement was related to cumulative fever burden, admission neurological grade, aneurysm obliteration procedure, admission computed tomographic score, vasospasm, and external ventricular drainage. Good-grade patients had worse functional outcomes with increased fever burden, and poor-grade patients improved more over time when fever burden was higher (time by World Federation of Neurological Surgeons grade by fever burden interaction, P < 0.001). Patients with vasospasm (P = 0.04) and patients with higher computed tomographic scores (P = 0.002) had worse 14-day outcomes but improved more over time. Bacteremia and ventriculitis were uncommon (<or=5%) and were not associated with higher fever burden. CONCLUSION Cumulative fever burden was associated with worse outcomes in good-grade patients and potential late recovery in poor-grade patients. Effective fever control in febrile subarachnoid hemorrhage patients may improve functional outcomes and hasten recovery.
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Affiliation(s)
- Andrew M Naidech
- Department of Neurology, Northwestern University, Chicago, Illinois, USA.
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Seule MA, Muroi C, Mink S, Yonekawa Y, Keller E. THERAPEUTIC HYPOTHERMIA IN PATIENTS WITH ANEURYSMAL SUBARACHNOID HEMORRHAGE, REFRACTORY INTRACRANIAL HYPERTENSION, OR CEREBRAL VASOSPASM. Neurosurgery 2009; 64:86-92; discussion 92-3. [DOI: 10.1227/01.neu.0000336312.32773.a0] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
To evaluate the feasibility and safety of mild hypothermia treatment in patients with aneurysmal subarachnoid hemorrhage (SAH) who are experiencing intracranial hypertension and/or cerebral vasospasm (CVS).
METHODS
Of 441 consecutive patients with SAH, 100 developed elevated intracranial pressure and/or symptomatic CVS refractory to conventional treatment. Hypothermia (33–34°C) was induced and maintained until intracranial pressure normalized, CVS resolved, or severe side effects occurred.
RESULTS
Thirteen patients were treated with hypothermia alone, and 87 were treated with hypothermia in combination with barbiturate coma. Sixty-six patients experienced poor-grade SAH (Hunt and Hess Grades IV and V) and 92 had Fisher Grade 3 and 4 bleedings. The mean duration of hypothermia was 169 ± 104 hours, with a maximum of 16.4 days. The outcome after 1 year was evaluated in 90 of 100 patients. Thirty-two patients (35.6%) survived with good functional outcome (Glasgow Outcome Scale [GOS] score, 4 and 5), 14 (15.5%) were severely disabled (GOS score, 3), 1 (1.1%) was in a vegetative state (GOS score, 2), and 43 (47.8%) died (GOS score, 1). The most frequent side effects were electrolyte disorders (77%), pneumonia (52%), thrombocytopenia (47%), and septic shock syndrome (40%). Of 93 patients with severe side effects, 6 (6.5%) died as a result of respiratory or multi-organ failure.
CONCLUSION
Prolonged systemic hypothermia may be considered as a last-resort option for a carefully selected group of SAH patients with intracranial hypertension or CVS resistant to conventional treatment. However, complications associated with hypothermia require elaborate protocols in general intensive care unit management.
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Affiliation(s)
- Martin A. Seule
- Neurointensive Care Unit, Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Carl Muroi
- Neurointensive Care Unit, Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Susanne Mink
- Neurointensive Care Unit, Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Yasuhiro Yonekawa
- Neurointensive Care Unit, Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Emanuela Keller
- Neurointensive Care Unit, Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
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Kiekkas P, Sakellaropoulos GC, Brokalaki H, Manolis E, Samios A, Skartsani C, Baltopoulos GI. Nursing Workload Associated With Fever in the General Intensive Care Unit. Am J Crit Care 2008. [DOI: 10.4037/ajcc2008.17.6.522] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background Fever in a patient in the intensive care unit necessitates several nursing tasks. Moreover, factors associated with increased patient care needs may be associated with fever.Objective To identify relationships between fever and characteristics of fever and nursing workload at the patient level.Methods A prospective study was conducted in a medical-surgical intensive care unit. The sample consisted of 361 patients consecutively admitted from October 2005 to August 2006. Each patient’s body temperature was measured by using a tympanic membrane or an axillary thermometer. The Therapeutic Intervention Scoring System-28 was used to measure nursing workload.Results A total of 188 patients (52.1%) had fever. Mean daily scores on the Therapeutic Intervention Scoring System and on 5 of its 7 categories were significantly higher for febrile patients than for nonfebrile patients. Fever was an independent predictor of the mean daily scores for all patients (P < .001). Peak body temperature but not duration of fever also was an independent predictor of mean daily scores for febrile patients (P < .001).Conclusion In a general intensive care unit, fever in patients should be taken into consideration for the proper allocation of nursing personnel.
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Affiliation(s)
- Panagiotis Kiekkas
- Panagiotis Kiekkas is a grade B nurse in the anesthesiology department, and Adamantios Samios and Chrisula Skartsani are grade A nurses in the intensive care unit at Patras University Hospital, Patras, Greece
| | - George C. Sakellaropoulos
- George C. Sakellaropoulos is an assistant professor in the Department of Medical Physics, University of Patras, Greece
| | - Hero Brokalaki
- Hero Brokalaki is an assistant professor, Evangelos Manolis is an associate professor, and George I. Baltopoulos is a professor in the School of Nursing, University of Athens, Greece
| | - Evangelos Manolis
- Hero Brokalaki is an assistant professor, Evangelos Manolis is an associate professor, and George I. Baltopoulos is a professor in the School of Nursing, University of Athens, Greece
| | - Adamantios Samios
- Panagiotis Kiekkas is a grade B nurse in the anesthesiology department, and Adamantios Samios and Chrisula Skartsani are grade A nurses in the intensive care unit at Patras University Hospital, Patras, Greece
| | - Chrisula Skartsani
- Panagiotis Kiekkas is a grade B nurse in the anesthesiology department, and Adamantios Samios and Chrisula Skartsani are grade A nurses in the intensive care unit at Patras University Hospital, Patras, Greece
| | - George I. Baltopoulos
- Hero Brokalaki is an assistant professor, Evangelos Manolis is an associate professor, and George I. Baltopoulos is a professor in the School of Nursing, University of Athens, Greece
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Abstract
Temperature management in acute neurologic disorders has received considerable attention in the last 2 decades. Numerous trials of hypothermia have been performed in patients with head injury, stroke, and cardiac arrest. This article reviews the physiology of thermoregulation and mechanisms responsible for hyperpyrexia. Detrimental effects of fever and benefits of normalizing elevated temperature in experimental models are discussed. This article presents a detailed analysis of trials of induced hypothermia in patients with acute neurologic insults and describes methods of fever control.
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Abstract
Increasing evidence suggests that induction of mild hypothermia (32-35 degrees C) in the first hours after an ischaemic event can prevent or mitigate permanent injuries. This effect has been shown most clearly for postanoxic brain injury, but could also apply to other organs such as the heart and kidneys. Hypothermia has also been used as a treatment for traumatic brain injury, stroke, hepatic encephalopathy, myocardial infarction, and other indications. Hypothermia is a highly promising treatment in neurocritical care; thus, physicians caring for patients with neurological injuries, both in and outside the intensive care unit, are likely to be confronted with questions about temperature management more frequently. This Review discusses the available evidence for use of controlled hypothermia, and also deals with fever control. Besides discussing the evidence, the aim is to provide information to help guide treatments more effectively with regard to timing, depth, duration, and effective management of side-effects. In particular, the rate of rewarming seems to be an important factor in establishing successful use of hypothermia in the treatment of neurological injuries.
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Affiliation(s)
- Kees H Polderman
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, Netherlands.
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Abstract
The brain reacts to injury or disease by cascades of cellular and molecular responses. Evidence suggests that immune-inflammatory processes are key elements in the physiopathological processes associated with brain injury or damage. Cytokines are among major mediators implicated in these processes. Cytokine responses in the initial phase of brain injury might have a role in aggravating brain damage. However, in later stages, these molecular mediators might contribute to recovery or repair. Hemodynamic stabilization and optimalization of oxygen delivery to the brain remain cornerstones in the management of acute brain injury. New approaches might use anticytokine therapy to limit progression and halt or attenuate secondary brain damage. Progress toward such novel neuroprotection strategies, however, awaits better understanding of the optimal timing and dosing of those neuromodulatory therapies and better knowledge of the numerous interactions of those mediators. This also requires understanding of how and when precisely immune mechanisms shift from noxious to protective or restorative actions.
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Affiliation(s)
- Hazim J. Kadhim
- Neuropathology Unit (Anatomic Pathology Service), Brugmann University Hospital and Pediatrics Service, Queen Fabiola Children's University Hospital, Free University of Brussels,
| | - Jean Duchateau
- Department of Immunology, Brugmann University Hospital, Free University of Brussels, Brussels, Belgium
| | - Guillaume Sébire
- Department of Child Neurology, CHU Fleurimont, and Neuroscience Center, Université de Sherbrooke, Quebec, Canada
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Theilen H, Ragaller M. [Therapy of hyperthermia in sepsis and septic shock. Necessary or injurious?]. Anaesthesist 2008; 56:949-52, 954-6. [PMID: 17554516 DOI: 10.1007/s00101-007-1211-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
In critically ill patients fever is associated with an increased morbidity and mortality rate. However, it remains unclear whether fever is an associated symptom of the underlying severe disease or a stimulator of specific pathophysiological cascades considered responsible for a deleterious outcome. Hyperthermia per se induces systemic changes like increased energy and oxygen demands, tachycardia, or fluid loss which might be harmful especially in septic patients due to congestion of the cardiovascular system. In this constellation a reduction of fever by antipyretic strategies might be indicated to decrease oxygen and energy demands. On the other hand the increasing body temperature obviously plays an important role in the inflammatory hemostasis during infections. Fever optimises humoral and cellular responses to infection and has some direct effects on bacteria and other microorganisms. Therefore, in severe sepsis or septic shock, fever reduction might impair the immune competency of the patients. According to the currently available evidence a body temperature higher than 40 degrees C is definitely harmful and should be treated in any case. A temperature range between 36 degrees C and 39 degrees C should be achieved for patients with severe sepsis and septic shock. At present there are no data showing the superiority of any of the different antipyrectic strategies in septic patients. Hence, external cooling with cold blankets or other devices may induce shivering of the muscles with a substantial increase of oxygen demand and is hardly tolerated in conscious patients. However, antipyretic therapy in patients with severe sepsis or septic shock should be indicated while considering the individual pathophysiology of every patient.
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Affiliation(s)
- H Theilen
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstrasse 74, 01307 Dresden.
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Cormio M, Citerio G. Continuous low dose diclofenac sodium infusion to control fever in neurosurgical critical care. Neurocrit Care 2007; 6:82-9. [PMID: 17522789 DOI: 10.1007/s12028-007-0002-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Aim of this randomized prospective clinical trial is to compare two methods of antipyretics and evaluate their efficacy in controlling fever during the acute phase of brain damage. METHODS Twenty-two febrile comatose patients: 12 severe traumatic brain injury and 10 subarachnoid hemorrhage divided in 2 groups: Diclofenac low-dose infusion (10 patients) and extemporaneous boluses of NSAIDs (CTRL, 12 patients). The primary outcome measure was length of time with temperature>38 degrees C. Secondary outcome measures were: 1) to assess the effects of each antipyretic strategy on intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial pressure (MAP) and heart rate; 2) to monitor adverse effects of each antipyretic strategy. The baseline characteristics in the two treatment groups were similar. RESULTS Primary findings: percentage of time per patient with temperature>38 degrees C was significantly lower (P<0.0001) in the DCF group, 4% (0-22%), vs. 34% (8-56%) in CTRL group. In addition, mean T degrees , max T degrees were lower in DCF than in CTRL (P<0.05). Secondary findings: CPP and MAP were significantly higher in DCF group (P<0.05) while ICP was not different (NS). However, if ICP pre randomization was <25 mmHg, CTRL suffered a worst ICP (24+/-11 vs. 16+/-7 P=0.01), MAP (89+/-10 vs. 104+/-10 P=0.01) and CPP (75+/-10 vs. 94+/-17 P=0.01) compared to DCF. No differences between the two treatment were recorded when ICP>or=25 mmHg before randomization. There was no gastrointestinal or intracranial bleeding. CONCLUSIONS Low dose DCF infusion is a potential useful strategy for a successful control temperature better than intermittent NSAIDs dosing, minimizing potentially brain-damaging effects of fever.
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Affiliation(s)
- Manuela Cormio
- Neurorianimazione, Dipartimento di Medicina Perioperatoria e Terapie Intensive, Ospedale San Gerardo, Via Pergolesi 33, 20052, Monza, MI, Italy
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Thompson HJ, Kirkness CJ, Mitchell PH, Webb DJ. Fever management practices of neuroscience nurses: national and regional perspectives. J Neurosci Nurs 2007; 39:151-62. [PMID: 17591411 PMCID: PMC2361150 DOI: 10.1097/01376517-200706000-00005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Neuroscience patients with fever may have worse outcomes than those who are afebrile. However, neuroscience nurses who encounter this common problem face a translational gap between patient-outcomes research and bedside practice because there is no current evidence-based standard of care for fever management of the neurologically vulnerable patient. The aim of this study was to determine if there are trends in national practices for fever and hyperthermia management of the neurologically vulnerable patient. A 15-item mailed questionnaire was used to determine national and regional trends in fever and hyperthermia management and decision making by neuroscience nurses. Members of the American Association of Neuroscience Nurses were surveyed (N = 1,225) and returned 328 usable surveys. Fewer than 20% of respondents reported having an explicit fever management protocol in place for neurologic patients, and 12.5% reported having a nonspecific patient protocol available for fever management. Several clear and consistent patterns in interventions for fever and hyperthermia management were seen nationally, including acetaminophen administration at a dose of 650 mg every 4 hours, ice packs, water cooling blankets, and tepid bathing. However, regional differences were seen in intervention choices and initial temperature to treat.
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Oh SJ, Hong YK, Song EK. Paroxysmal autonomic dysregulation with fever that was controlled by propranolol in a brain neoplasm patient. Korean J Intern Med 2007; 22:51-4. [PMID: 17427648 PMCID: PMC2687607 DOI: 10.3904/kjim.2007.22.1.51] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Intractable fever in cancer patients is problematic and the causes of this fever can be diverse. Paroxysmal persistent hyperthermia after sudden mental change or neurologic deficit can develop via autonomic dysregulation without infection or any other causes of fever. Paroxysmal hyperthermic autonomic dysregulation is a rare disease entity. It manifests as a form of paroxysmal hypertension, fever, tachycardia, tachypnea, pupillary dilation, agitation and extensor posturing after traumatic brain injury, hydrocephalus, brain hemorrhage or brain neoplasm. We recently experienced a case of paroxysmal hyperthermia following intracerebral hemorrhage along with brain neoplasm. Extensive fever workups failed to show an infectious or inflammatory source and/or hormonal abnormality. Empirical treatments with antibiotics, antipyretics, morphine, steroid and antiepileptic agents were also ineffective. However, Propranolol, a lipophilic beta-blocker, successfully controlled the fever and stabilized the patient. Fever in cancer patients is a common phenomenon, but a central origin should be considered when the fever is intractable. Propranolol is one of the most effective drugs for treating paroxysmal hyperthermia that is due to autonomic dysregulation.
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Affiliation(s)
- Su Jin Oh
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
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Cremer OL, Kalkman CJ. Cerebral pathophysiology and clinical neurology of hyperthermia in humans. PROGRESS IN BRAIN RESEARCH 2007; 162:153-69. [PMID: 17645919 DOI: 10.1016/s0079-6123(06)62009-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Deliberate hyperthermia has been used clinically as experimental therapy for neoplastic and infectious diseases. Several case fatalities have occurred with this form of treatment, but most were attributable to systemic complications rather than central nervous system toxicity. Nonetheless, demyelating peripheral neuropathy and neurological symptoms of nausea, delirium, apathy, stupor, and coma have been reported. Temperatures exceeding 40 degrees C cause transient vasoparalysis in humans, resulting in cerebral metabolic uncoupling and loss of pressure-flow autoregulation. These findings may be related to the development of brain edema, intracerebral hemorrhage, and intracranial hypertension observed after prolonged therapeutic hyperthermia. Furthermore, deliberate hyperthermia critically worsens the extent of histopathological damage in animal models of traumatic, ischemic, and hypoxic brain injury. However, it is unknown whether these findings translate to episodes of spontaneous fever in neurologically injured patients. In a clinical setting fever is a strong prognostic marker of a patient's primary degree of neuronal damage, and a causal relation with long-term functional neurological outcome has not been established for most types of brain injury. Furthermore, in the neurosurgical intensive-care unit fever is extremely common whereas antipyretic therapy is only poorly effective. Therefore maintaining strict normothermia may be an impossible goal in many patients. Although there are several physiological arguments for avoiding exogenous hyperthermia in neurologically injured patients, there is no evidence that aggressive attempts at controlling spontaneous fever can improve clinical outcome.
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Affiliation(s)
- Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center, Q04.460, PO Box 85500, 3508 GA Utrecht, The Netherlands.
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Abstract
Fever is a common occurrence in patients following brain and spinal cord injury (SCI). In intensive care units, large numbers of patients demonstrate febrile periods during the first several days after injury. Over the last several years, experimental studies have reported the detrimental effects of fever in various models of central nervous system (CNS) injury. Small elevations in temperature during or following an insult have been shown to worsen histopathological and behavioral outcome. Thus, the control of fever after brain or SCI may improve outcome if more effective strategies for monitoring and treating hyperthermia were developed. Because of the clinical importance of fever as a potential secondary injury mechanism, mechanisms underlying the detrimental effects of mild hyperthermia after injury have been evaluated. To this end, studies have shown that mild hyperthermia (>37 degrees C) can aggravate multiple pathomechanisms, including excitotoxicity, free radical generation, inflammation, apoptosis, and genetic responses to injury. Recent data indicate that gender differences also play a role in the consequences of secondary hyperthermia in animal models of brain injury. The observation that dissociations between brain and body temperature often occur in head-injured patients has again emphasized the importance of controlling temperature fluctuations after injury. Thus, increased emphasis on the ability to monitor CNS temperature and prevent periods of fever has gained increased attention in the clinical literature. Cooling blankets, body vests, and endovascular catheters have been shown to prevent elevations in body temperature in some patient populations. This chapter will summarize evidence regarding hyperthermia and CNS injury.
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Affiliation(s)
- W Dalton Dietrich
- Department of Neurological Surgery, Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, FL 33136, USA.
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49
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Abstract
Temperature management in acute neurologic disorders has received considerable attention in the last 2 decades. Numerous trials of hypothermia have been performed in patients with head injury, stroke, and cardiac arrest. This article reviews the physiology of thermoregulation and mechanisms responsible for hyperpyrexia. Detrimental effects of fever and benefits of normalizing elevated temperature in experimental models are discussed. This article presents a detailed analysis of trails of induced hypothermia in patients with acute neurologic insults and describes methods of fever control.
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Affiliation(s)
- Yekaterina K Axelrod
- Department of Neurology, Washington University School of Medicine, St Louis, MO 63110-1093, USA
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Himmelseher S, Werner C. Temperaturmanagement nach Schädel-Hirn-Trauma in der prähospitalen Notfallversorgung. Notf Rett Med 2006. [DOI: 10.1007/s10049-006-0801-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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