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Early predictors of brain injury in patients with acute carbon monoxide poisoning and the neuroprotection of mild hypothermia. Am J Emerg Med 2022; 61:18-28. [PMID: 36029667 DOI: 10.1016/j.ajem.2022.08.016] [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: 04/14/2022] [Revised: 07/13/2022] [Accepted: 08/07/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Carbon monoxide (CO) poisoning can cause serious neurological sequelae. However, there is neither effective treatment strategy nor reliable indicators to determine the prognosis of patients with CO poisoning. The present study aimed to observe the changes of neurological function score, disease severity score, cerebral oxygen utilization (O2UCc), bispectral (BIS) index and neuron-specific enolase (NSE) concentration, and to elucidate the clinical significance of these potential indicators and the neuroprotective effect of mild hypothermia on brain injury in patients with severe acute CO poisoning. MATERIALS AND METHODS A total of 277 patients with acute severe CO poisoning from 2013 to 2018 were enrolled in our hospital. Patients were divided into three groups according to their body temperature on the day of admission and their willingness to treat: a fever group (n = 78), a normal temperature group (NT group, n = 113), and a mild hypothermia group (MH group, n = 86). All patients were given hyperbaric oxygen therapy, while those in the MH group received additional mild hypothermia treatment. The severity of the disease, the neurobehavioral status, the incidence of delayed encephalopathy after acute carbon monoxide poisoning (DEACMP), and other indicators including BIS, O2UCc, NSE were further evaluated in all patients at given time-points. RESULTS Mild hypothermia therapy improved the prognosis of patients with CO poisoning, significantly decreased the value of O2UCc and NSE, and up-regulated BIS. The incidence of DEACMP at 6 months was 27% in the fever group, 23% in the NT group, and 8% in the MH group. The values of Glasgow-Pittsburgh coma scale (G-P score), BIS index and NSE were closely related to the occurrence of DEACMP, the cutoff values were 12.41, 52.17 and 35.20 ng/mL, and the sensitivity and specificity were 79.3%, 77.6%, 79.3% and 67.6%, 89.5%, 88.6% in the receiver operating characteristic curve (ROC), respectively. CONCLUSIONS Early mild hypothermia treatment could significantly reduce the severity of brain injury after CO poisoning, and might be further popularized in clinic. G-P scores, NSE and BIS index can be regarded as the prediction indicators in the occurrence and development of DEACMP. CLINICAL TRIAL REGISTRATION The study protocol was granted from Qingdao University Research Ethics Committee (Clinical trial registry and ethical approval number: QD81571283).
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Hergenroeder GW, Yokobori S, Choi HA, Schmitt K, Detry MA, Schmitt LH, McGlothlin A, Puccio AM, Jagid J, Kuroda Y, Nakamura Y, Suehiro E, Ahmad F, Viele K, Wilde EA, McCauley SR, Kitagawa RS, Temkin NR, Timmons SD, Diringer MN, Dash PK, Bullock R, Okonkwo DO, Berry DA, Kim DH. Hypothermia for Patients Requiring Evacuation of Subdural Hematoma: A Multicenter Randomized Clinical Trial. Neurocrit Care 2021; 36:560-572. [PMID: 34518968 PMCID: PMC8964656 DOI: 10.1007/s12028-021-01334-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/13/2021] [Indexed: 11/24/2022]
Abstract
Background Hypothermia is neuroprotective in some ischemia–reperfusion injuries. Ischemia–reperfusion injury may occur with traumatic subdural hematoma (SDH). This study aimed to determine whether early induction and maintenance of hypothermia in patients with acute SDH would lead to decreased ischemia–reperfusion injury and improve global neurologic outcome. Methods This international, multicenter randomized controlled trial enrolled adult patients with SDH requiring evacuation of hematoma within 6 h of injury. The intervention was controlled temperature management of hypothermia to 35 °C prior to dura opening followed by 33 °C for 48 h compared with normothermia (37 °C). Investigators randomly assigned patients at a 1:1 ratio between hypothermia and normothermia. Blinded evaluators assessed outcome using a 6-month Glasgow Outcome Scale Extended score. Investigators measured circulating glial fibrillary acidic protein and ubiquitin C-terminal hydrolase L1 levels. Results Independent statisticians performed an interim analysis of 31 patients to assess the predictive probability of success and the Data and Safety Monitoring Board recommended the early termination of the study because of futility. Thirty-two patients, 16 per arm, were analyzed. Favorable 6-month Glasgow Outcome Scale Extended outcomes were not statistically significantly different between hypothermia vs. normothermia groups (6 of 16, 38% vs. 4 of 16, 25%; odds ratio 1.8 [95% confidence interval 0.39 to ∞], p = .35). Plasma levels of glial fibrillary acidic protein (p = .036), but not ubiquitin C-terminal hydrolase L1 (p = .26), were lower in the patients with favorable outcome compared with those with unfavorable outcome, but differences were not identified by temperature group. Adverse events were similar between groups. Conclusions This trial of hypothermia after acute SDH evacuation was terminated because of a low predictive probability of meeting the study objectives. There was no statistically significant difference in functional outcome identified between temperature groups. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01334-w.
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Affiliation(s)
- Georgene W Hergenroeder
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA. .,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA.
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Huimahn Alex Choi
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Karl Schmitt
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Michelle A Detry
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Lisa H Schmitt
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Anna McGlothlin
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan Jagid
- Department of Neurological Surgery, Jackson Memorial Hospital, University of Miami, Miami, FL, USA
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Kagawa University Hospital, Kagawa Prefecture, Japan
| | - Yukihiko Nakamura
- Emergency and Critical Care Medicine, Kurume University Hospital, Fukuoka, Japan
| | - Eiichi Suehiro
- Department of Neurosurgery, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Faiz Ahmad
- Department of Neurological Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Kert Viele
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Elisabeth A Wilde
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Stephen R McCauley
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Ryan S Kitagawa
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Nancy R Temkin
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle, WA, USA
| | - Shelly D Timmons
- Department of Neurological Surgery, Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael N Diringer
- Departments of Neurology, Neurological Surgery, Anesthesiology, and Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Pramod K Dash
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Department of Neurobiology and Anatomy, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ross Bullock
- Department of Neurological Surgery, Jackson Memorial Hospital, University of Miami, Miami, FL, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Donald A Berry
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Dong H Kim
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
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von Steinbuechel N, Rauen K, Krenz U, Wu YJ, Covic A, Plass AM, Cunitz K, Mueller I, Bockhop F, Polinder S, Wilson L, Steyerberg EW, Maas AIR, Menon D, Zeldovich M. Translation and Linguistic Validation of Outcome Instruments for Traumatic Brain Injury Research and Clinical Practice: A Step-by-Step Approach within the Observational CENTER-TBI Study. J Clin Med 2021; 10:2863. [PMID: 34203325 PMCID: PMC8269004 DOI: 10.3390/jcm10132863] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/16/2022] Open
Abstract
Assessing outcomes in multinational studies on traumatic brain injury (TBI) poses major challenges and requires relevant instruments in languages other than English. Of the 19 outcome instruments selected for use in the observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, 17 measures lacked translations in at least one target language. To fill this gap, we aimed to develop well-translated linguistically and psychometrically validated instruments. We performed translations and linguistic validations of patient-reported measures (PROMs), clinician-reported (ClinRO), and performance-based (PerfO) outcome instruments, using forward and backward translations, reconciliations, cognitive debriefings with up to 10 participants, iterative revisions, and international harmonization with input from over 150 international collaborators. In total, 237 translations and 211 linguistic validations were carried out in up to 20 languages. Translations were evaluated at the linguistic and cultural level by coding changes when the original versions are compared with subsequent translation steps, using the output of cognitive debriefings, and using comprehension rates. The average comprehension rate per instrument varied from 88% to 98%, indicating a good quality of the translations. These outcome instruments provide a solid basis for future TBI research and clinical practice and allow the aggregation and analysis of data across different countries and languages.
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Affiliation(s)
- Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Katrin Rauen
- Department of Geriatric Psychiatry, Psychiatric Hospital Zurich, University of Zurich, Minervastrasse 145, 8032 Zurich, Switzerland; or
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Feodor-Lynen-Straße 17, 81377 Munich, Germany
| | - Ugne Krenz
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Yi-Jhen Wu
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Amra Covic
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Anne Marie Plass
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Katrin Cunitz
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Isabelle Mueller
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Fabian Bockhop
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (S.P.); (E.W.S.)
| | - Lindsay Wilson
- Department of Psychology, University of Stirling, Stirling FK9 4LJ, UK;
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (S.P.); (E.W.S.)
- Department of Biomedical Data Sciences, Leiden University Medical Center, 2333 RC Leiden, The Netherlands
| | - Andrew I. R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, 2650 Edegem, Belgium;
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Box 157, Cambridge CB2 0QQ, UK;
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany; (U.K.); (Y.-J.W.); (A.C.); (A.M.P.); (K.C.); (I.M.); (F.B.); (M.Z.)
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Effect of selective brain cooling versus core cooling on achieving target temperature among patients with severe traumatic brain injury. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2020. [DOI: 10.1016/j.ijans.2020.100209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
OBJECTIVES The Eurotherm3235 trial showed that therapeutic hypothermia was deleterious in patients with raised intracranial pressure following traumatic brain injury. We sought to ascertain if increased temperature variability within the first 48 hours, or for 7 days post randomization, were modifiable risk factors associated with poorer outcome. DESIGN Eurotherm3235 was a multicenter randomized controlled trial. Patients were randomized to receive either therapeutic hypothermia in addition to standard care or the later only. Mean moving range (mr) was used to stratify subjects into tertiles by the variability present in their core temperature within the first 48 hours post randomization and within 7 days post randomization. The primary outcome measure was a collapsed Glasgow Outcome Scale-Extended at 6 months post randomization. The temperature variability effect was estimated with ordinal logistic regression adjusted for baseline covariates and treatment effect. SETTING Forty-seven critical care units in 18 countries. PATIENTS Patients enrolled in the Eurotherm3235 trial to either therapeutic hypothermia or control treatments only. MEASUREMENTS AND MAIN RESULTS Three hundred eighty-six patients were included in our study. High level of temperature variability during the first 48 hours was associated with poorer collapsed Glasgow Outcome Scale-Extended. This effect remained statistically significant when only the control arm of the study was analyzed. No statistically significant effect was seen within the first 48 hours in the hypothermia group or within 7 days in either group. CONCLUSIONS When targeting normothermia, temperature variability may be a statistically significant variable in an ordinal analysis adjusted for baseline covariates.
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Andrews PJ, Sinclair HL, Rodríguez A, Harris B, Rhodes J, Watson H, Murray G. Therapeutic hypothermia to reduce intracranial pressure after traumatic brain injury: the Eurotherm3235 RCT. Health Technol Assess 2019; 22:1-134. [PMID: 30168413 DOI: 10.3310/hta22450] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of disability and death in young adults worldwide. It results in around 1 million hospital admissions annually in the European Union (EU), causes a majority of the 50,000 deaths from road traffic accidents and leaves a further ≈10,000 people severely disabled. OBJECTIVE The Eurotherm3235 Trial was a pragmatic trial examining the effectiveness of hypothermia (32-35 °C) to reduce raised intracranial pressure (ICP) following severe TBI and reduce morbidity and mortality 6 months after TBI. DESIGN An international, multicentre, randomised controlled trial. SETTING Specialist neurological critical care units. PARTICIPANTS We included adult participants following TBI. Eligible patients had ICP monitoring in place with an ICP of > 20 mmHg despite first-line treatments. Participants were randomised to receive standard care with the addition of hypothermia (32-35 °C) or standard care alone. Online randomisation and the use of an electronic case report form (CRF) ensured concealment of random treatment allocation. It was not possible to blind local investigators to allocation as it was obvious which participants were receiving hypothermia. We collected information on how well the participant had recovered 6 months after injury. This information was provided either by the participant themself (if they were able) and/or a person close to them by completing the Glasgow Outcome Scale - Extended (GOSE) questionnaire. Telephone follow-up was carried out by a blinded independent clinician. INTERVENTIONS The primary intervention to reduce ICP in the hypothermia group after randomisation was induction of hypothermia. Core temperature was initially reduced to 35 °C and decreased incrementally to a lower limit of 32 °C if necessary to maintain ICP at < 20 mmHg. Rewarming began after 48 hours if ICP remained controlled. Participants in the standard-care group received usual care at that centre, but without hypothermia. MAIN OUTCOME MEASURES The primary outcome measure was the GOSE [range 1 (dead) to 8 (upper good recovery)] at 6 months after the injury as assessed by an independent collaborator, blind to the intervention. A priori subgroup analysis tested the relationship between minimisation factors including being aged < 45 years, having a post-resuscitation Glasgow Coma Scale (GCS) motor score of < 2 on admission, having a time from injury of < 12 hours and patient outcome. RESULTS We enrolled 387 patients from 47 centres in 18 countries. The trial was closed to recruitment following concerns raised by the Data and Safety Monitoring Committee in October 2014. On an intention-to-treat basis, 195 participants were randomised to hypothermia treatment and 192 to standard care. Regarding participant outcome, there was a higher mortality rate and poorer functional recovery at 6 months in the hypothermia group. The adjusted common odds ratio (OR) for the primary statistical analysis of the GOSE was 1.54 [95% confidence interval (CI) 1.03 to 2.31]; when the GOSE was dichotomised the OR was 1.74 (95% CI 1.09 to 2.77). Both results favoured standard care alone. In this pragmatic study, we did not collect data on adverse events. Data on serious adverse events (SAEs) were collected but were subject to reporting bias, with most SAEs being reported in the hypothermia group. CONCLUSIONS In participants following TBI and with an ICP of > 20 mmHg, titrated therapeutic hypothermia successfully reduced ICP but led to a higher mortality rate and worse functional outcome. LIMITATIONS Inability to blind treatment allocation as it was obvious which participants were randomised to the hypothermia group; there was biased recording of SAEs in the hypothermia group. We now believe that more adequately powered clinical trials of common therapies used to reduce ICP, such as hypertonic therapy, barbiturates and hyperventilation, are required to assess their potential benefits and risks to patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN34555414. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 45. See the NIHR Journals Library website for further project information. The European Society of Intensive Care Medicine supported the pilot phase of this trial.
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Affiliation(s)
- Peter Jd Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - H Louise Sinclair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Aryelly Rodríguez
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Bridget Harris
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Gordon Murray
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Affiliation(s)
- Annemarie Docherty
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Chancellor's Building, Little France, Edinburgh, United Kingdom
| | - John Emelifeonwu
- Department of Neurosurgery & Centre for Clinical Brain Sciences, University of Edinburgh & NHS Lothian, Western General Hospital, Edinburgh EH4 2XU, United Kingdom
| | - Peter J D Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh & NHS Lothian, Western General Hospital, Edinburgh EH4 2XU, United Kingdom
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Fazel Bakhsheshi M, Keenliside L, Lee TY. A novel selective cooling system for the brain: feasibility study in rabbits vs piglets. Intensive Care Med Exp 2018; 6:45. [PMID: 30387029 PMCID: PMC6212374 DOI: 10.1186/s40635-018-0211-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 10/21/2018] [Indexed: 01/09/2023] Open
Abstract
Background Selective brain cooling (SBC) methods could alleviate the complications associated with systemic hypothermia. The authors (MFB, LK, and T-YL) have developed a simple and an effective nasopharyngeal SBC method using a vortex tube. The primary focus of the study is to evaluate the effectiveness of this approach on rabbits and compare it with our previous published finding on piglets, which are mammals without and with a carotid rete, respectively. Methods Experiments were conducted on six rabbits. Body temperature was measured continuously using an esophageal temperature probe while brain temperature was measured with an implanted thermometer. Two successive experiments were performed on each animal. In the first experiment, brain cooling was initiated by blowing room temperature air from the hospital medical air outlet, at a flow rate of 14–15 L/min into both nostrils for 60 min. The second series of measurements and brain cooling was performed in the same manner as the first one but blowing cold air (− 7 °C) at the same flow rate. Results One hour post cooling with room temperature air at a flow rate of 14–15 L/min, the brain temperature was 34.2 ± 1.2 °C which resulted in mean brain cooling rates of 3.7 ± 0.9 °C/h. Brain temperature could be reduced more rapidly at mean rates of 5.2 ± 1.9 °C/h, while the body temperature as measured by the esophageal temperature probe was maintained above 36 °C during cooling and maintaining period. Conclusions We have demonstrated that using the vortex tube allows initial rapid and SBC in rabbits. Moreover, comparing results between piglets and rabbits demonstrates clearly that the lack of a carotid rete does not prevent specific cooling of the brain by means of the nasopharyngeal method.
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Affiliation(s)
- Mohammad Fazel Bakhsheshi
- Imaging Program, Lawson Health Research Institute, London, Ontario, Canada. .,Imaging Research Laboratories, Robarts Research Institute, 100 Perth Drive, P.O. Box 5015, London, Ontario, N6A 5k8, Canada.
| | - Lynn Keenliside
- Imaging Program, Lawson Health Research Institute, London, Ontario, Canada
| | - Ting-Yim Lee
- Imaging Program, Lawson Health Research Institute, London, Ontario, Canada.,Imaging Research Laboratories, Robarts Research Institute, 100 Perth Drive, P.O. Box 5015, London, Ontario, N6A 5k8, Canada.,Departments of Medical Imaging and Biophysics, The University of Western Ontario, London, Ontario, Canada
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Kim YS, Cho YH, Sung K, Ryu JA, Chung CR, Suh GY, Yang JH, Yang JH. Target Temperature Management May Not Improve Clinical Outcomes of Extracorporeal Cardiopulmonary Resuscitation. J Intensive Care Med 2018; 34:790-796. [DOI: 10.1177/0885066618801269] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: Target temperature management (TTM) and extracorporeal cardiopulmonary resuscitation (ECPR) have been established as important interventions during cardiopulmonary arrest. However, the impact of combined TTM and ECPR on clinical outcomes has not been studied in detail. Methods: We reviewed the records of 245 patients who received extracorporeal life support (ECLS) between January 2012 and June 2015. Exclusion criteria were as follows: Extracorporeal life support performed for reasons other than cardiac arrest, age less than 18 years, and death within 24 hours. A total of 101 patients were finally included in the study. Twenty-five patients underwent TTM, and 76 patients did not. Results: The patients’ mean age was 55 ± 16.7 years. The mean cardiac arrest time was 44.6 ± 33.5 minutes. There were 84 patients whose cardiac arrest was due to a cardiac cause (83.2%) and 79 patients with in-hospital cardiac arrest (78.2%). There was a significant difference in average body temperature during the first 24 hours following ECPR (33.4°C vs 35.6°C; P = .001). The overall favorable neurological outcome rate was 34% and hospital survival rate was 47%. There was no difference in favorable neurological outcomes and hospital survival between the TTM and non-TTM groups ( P = .91 and .84, respectively). On multivariate analysis of neurological outcomes and hospital survival, TTM was not a significant prognostic factor. Conclusion: We did not observe any benefits of TTM in patients undergoing ECPR. Natural hypothermia or normothermia related to ECLS may explain this result. Further research is needed to understand the role of TTM in ECPR.
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Affiliation(s)
- Young Su Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong-Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji-Hyuk Yang
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Dietrich WD, Bramlett HM. Therapeutic hypothermia and targeted temperature management for traumatic brain injury: Experimental and clinical experience. Brain Circ 2017; 3:186-198. [PMID: 30276324 PMCID: PMC6057704 DOI: 10.4103/bc.bc_28_17] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 11/20/2017] [Accepted: 11/24/2017] [Indexed: 12/21/2022] Open
Abstract
Traumatic brain injury (TBI) is a worldwide medical problem, and currently, there are few therapeutic interventions that can protect the brain and improve functional outcomes in patients. Over the last several decades, experimental studies have investigated the pathophysiology of TBI and tested various pharmacological treatment interventions targeting specific mechanisms of secondary damage. Although many preclinical treatment studies have been encouraging, there remains a lack of successful translation to the clinic and no therapeutic treatments have shown benefit in phase 3 multicenter trials. Therapeutic hypothermia and targeted temperature management protocols over the last several decades have demonstrated successful reduction of secondary injury mechanisms and, in some selective cases, improved outcomes in specific TBI patient populations. However, the benefits of therapeutic hypothermia have not been demonstrated in multicenter randomized trials to significantly improve neurological outcomes. Although the exact reasons underlying the inability to translate therapeutic hypothermia into a larger clinical population are unknown, this failure may reflect the suboptimal use of this potentially powerful therapeutic in potentially treatable severe trauma patients. It is known that multiple factors including patient recruitment, clinical treatment variables, and cooling methodologies are all important in yielding beneficial effects. High-quality multicenter randomized controlled trials that incorporate these factors are required to maximize the benefits of this experimental therapy. This article therefore summarizes several factors that are important in enhancing the beneficial effects of therapeutic hypothermia in TBI. The current failures of hypothermic TBI clinical trials in terms of clinical protocol design, patient section, and other considerations are discussed and future directions are emphasized.
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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, FL, USA
| | - Helen M Bramlett
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
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Choudhary RC, Jia X. Hypothalamic or Extrahypothalamic Modulation and Targeted Temperature Management After Brain Injury. Ther Hypothermia Temp Manag 2017; 7:125-133. [PMID: 28467285 PMCID: PMC5610405 DOI: 10.1089/ther.2017.0003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Targeted temperature management (TTM) has been recognized to protect tissue function and positively influence neurological outcomes after brain injury. While shivering during hypothermia nullifies the beneficial effect of TTM, traditionally, antishivering drugs or paralyzing agents have been used to reduce the shivering. The hypothalamic area of the brain helps in controlling cerebral temperature and body temperature through interactions between different brain areas. Thus, modulation of different brain areas either pharmacologically or by electrical stimulation may contribute in TTM; although, very few studies have shown that TTM might be achieved by activation and inhibition of neurons in the hypothalamic region. Recent studies have investigated potential pharmacological methods of inducing hypothermia for TTM by aiming to maintain the TTM and reduce the shivering effect without using antiparalytic drugs. Better survival and neurological outcome after brain injury have been reported after pharmacologically induced TTM. This review discusses the mechanisms and modulation of the hypothalamus with other brain areas that are involved in inducing hypothermia through which TTM may be achieved and provides therapeutic strategies for TTM after brain injury.
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Affiliation(s)
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Orthopedics, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Mortality Risk Stratification After Traumatic Brain Injury and Hazard of Death With Titrated Hypothermia in the Eurotherm3235Trial. Crit Care Med 2017; 45:883-890. [PMID: 28277415 PMCID: PMC5389587 DOI: 10.1097/ccm.0000000000002376] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Objectives: Hypothermia reduces intracranial hypertension in patients with traumatic brain injury but was associated with harm in the Eurotherm3235Trial. We stratified trial patients by International Mission for Prognosis and Analysis of Clinical Trials in [Traumatic Brain Injury] (IMPACT) extended model sum scores to determine where the balance of risks lay with the intervention. Design: The Eurotherm3235Trial was a randomized controlled trial, with standardized and blinded outcome assessment. Patients in the trial were split into risk tertiles by IMPACT extended model sum scores. A proportional hazard analysis for death between randomization and 6 months was performed by intervention and IMPACT extended model sum scores tertiles in both the intention-to-treat and the per-protocol populations of the Eurotherm3235Trial. Setting: Forty-seven neurologic critical care units in 18 countries. Patients: Adult traumatic brain injury patients admitted to intensive care who had suffered a primary, closed traumatic brain injury; increased intracranial pressure; an initial head injury less than 10 days earlier; a core temperature at least 36°C; and an abnormal brain CT. Intervention: Titrated Hypothermia in the range 32-35°C as the primary intervention to reduce raised intracranial pressure. Measurements and Main Results: Three hundred eighty-six patients were available for analysis in the intention-to-treat and 257 in the per-protocol population. The proportional hazard analysis (intention-to-treat and per-protocol populations) showed that the treatment effect behaves similarly across all risk stratums. However, there is a trend that indicates that patients in the low-risk group could be at greater risk of suffering harm due to hypothermia. Conclusions: Hypothermia as a first line measure to reduce intracranial pressure to less than 20 mm Hg is harmful in patients with a lower severity of injury and no clear benefit exists in patients with more severe injuries.
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Abstract
Since traumatic brain injury is the most common cause of long-term disability and death among young adults, it represents an enormous socio-economic and healthcare burden. As a consequence of the primary lesion, a perifocal brain edema develops causing an elevation of the intracranial pressure due to the limited intracranial space. This entails a reduction of the cerebral perfusion pressure and the cerebral blood flow. A cerebral perfusion deficit below the threshold for ischemia leads to further ischemic lesions and to a progression of the contusion. As the irreversible primary lesion can only be inhibited by primary prevention, the therapy of traumatic brain injury focuses on the secondary injuries. The treatment consists of surgical therapy evacuating the space-occupying intracranial lesion and conservative intensive medical care. Due to the complex pathophysiology the therapy of traumatic brain injury should be rapidly performed in a neurosurgical unit.
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Rim HT, Ahn JH, Kim JH, Oh JK, Song JH, Chang IB. Therapeutic Hypothermia for Increased Intracranial Pressure after Decompressive Craniectomy: A Single Center Experience. Korean J Neurotrauma 2016; 12:55-60. [PMID: 27857908 PMCID: PMC5110919 DOI: 10.13004/kjnt.2016.12.2.55] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/30/2016] [Accepted: 10/12/2016] [Indexed: 01/19/2023] Open
Abstract
Objective Therapeutic hypothermia (TH) and decompressive craniectomy are neuroprotective interventions following severe brain swelling. The precise benefits, risks, and clinical outcomes in brain swelling after TH are still being investigated. We aimed to investigate the effects of TH in severe brain injury after decompressive craniectomy. Methods We reviewed the cases of 24 patients who underwent decompressive craniectomy with intracranial pressure (ICP) monitor insertion in one medical center between January 2012 and May 2016. All patients had an ICP greater than 15 mmHg and a Glasgow Coma Scale score of less than 7 at the time of intervention. TH was induced in half of the patients (n=12) directly after surgery; the remaining 12 patients remained normothermic. The ICP, vital signs, complications, and functional outcomes were reviewed and compared between the patient groups. Results The mean ICP in the TH group was significantly lower than in the normothermia group. Complications during the 3 days after surgery were not different between the groups, with the exception of hypokalemia in the TH group. Mortality in the intensive care unit (ICU) was higher in the normothermia group, but the functional outcomes 3 months after surgery were not different between the TH and normothermia groups. Conclusion TH after decompressive craniectomy was effective for lowering ICP in patients with severe brain swelling. TH also reduced mortality in the ICU, but it had no benefit in functional outcomes.
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Affiliation(s)
- Hyun Taek Rim
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jun Hyong Ahn
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Ji Hee Kim
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jae Keun Oh
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Joon Ho Song
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - In Bok Chang
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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Subnormothermic Perfusion in the Isolated Rat Liver Preserves the Antioxidant Glutathione and Enhances the Function of the Ubiquitin Proteasome System. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2016; 2016:9324692. [PMID: 27800122 PMCID: PMC5075307 DOI: 10.1155/2016/9324692] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/09/2016] [Accepted: 09/15/2016] [Indexed: 12/18/2022]
Abstract
The reduction of oxidative stress is suggested to be one of the main mechanisms to explain the benefits of subnormothermic perfusion against ischemic liver damage. In this study we investigated the early cellular mechanisms induced in isolated rat livers after 15 min perfusion at temperatures ranging from normothermia (37°C) to subnormothermia (26°C and 22°C). Subnormothermic perfusion was found to maintain hepatic viability. Perfusion at 22°C raised reduced glutathione levels and the activity of glutathione reductase; however, lipid and protein oxidation still occurred as determined by malondialdehyde, 4-hydroxynonenal-protein adducts, and advanced oxidation protein products. In livers perfused at 22°C the lysosomal and ubiquitin proteasome system (UPS) were both activated. The 26S chymotrypsin-like (β5) proteasome activity was significantly increased in the 26°C (46%) and 22°C (42%) groups. The increased proteasome activity may be due to increased Rpt6 Ser120 phosphorylation, which is known to enhance 26S proteasome activity. Together, our results indicate that the early events produced by subnormothermic perfusion in the liver can induce oxidative stress concomitantly with antioxidant glutathione preservation and enhanced function of the lysosomal and UPS systems. Thus, a brief hypothermia could trigger antioxidant mechanisms and may be functioning as a preconditioning stimulus.
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Fazel Bakhsheshi M, Wang Y, Keenliside L, Lee TY. A new approach to selective brain cooling by a Ranque-Hilsch vortex tube. Intensive Care Med Exp 2016; 4:32. [PMID: 27686339 PMCID: PMC5042908 DOI: 10.1186/s40635-016-0102-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 09/08/2016] [Indexed: 11/29/2022] Open
Abstract
Background Target temperature management is the single most effective intervention and the gold standard in post-resuscitation care today. However, cooling the whole body below 33–34 °C can cause severe complications. Therefore, developing a selective brain cooling (SBC) approach which can be initiated early to induce rapid cooling and maintain the target temperature over 12–24 h before slowly rewarming brain temperature by itself alone would be advantageous. Vortex tubes are simple mechanical devices generating cold air from a stream of compressed air without applied chemical or energy. This study investigated whether blowing cooled air from a vortex tube into the nasal cavities is safe and effective to selectively reduce and maintain before slowly rewarming brain temperature back to normal temperature. Methods Experiments were conducted on ten juvenile pigs. Body temperature was measured using an esophageal and a rectal temperature probe while brain temperature with an intraparenchymal thermocouple probe. Cerebral blood flow (CBF) was measured with CT perfusion. Results Brain temperature dropped below 34 °C within 30–40 min while a brain-esophageal temperature difference greater than 3 °C was maintained over 6 h. There was no evidence of nasal or nasopharynx mucosal swelling, necrosis, or hemorrhage on MRI examination. CBF first decreased and then stabilized together with brain temperature before increasing to the baseline level during rewarming. Conclusions SBC was accomplished by blowing cold air from a vortex tube into the nasal cavities. Due to its portability, the method can be used continuously in resuscitated patients in both in- and out-of-hospital situations without interruption.
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Affiliation(s)
- Mohammad Fazel Bakhsheshi
- Imaging Program, Lawson Health Research Institute, London, ON, Canada. .,Imaging Research Laboratories, Robarts Research Institute, 1151 Richmond Street North, London, ON, N6A 5B7, Canada.
| | - Yong Wang
- Imaging Program, Lawson Health Research Institute, London, ON, Canada.,Imaging Research Laboratories, Robarts Research Institute, 1151 Richmond Street North, London, ON, N6A 5B7, Canada
| | - Lynn Keenliside
- Imaging Program, Lawson Health Research Institute, London, ON, Canada.,Imaging Research Laboratories, Robarts Research Institute, 1151 Richmond Street North, London, ON, N6A 5B7, Canada
| | - Ting-Yim Lee
- Imaging Program, Lawson Health Research Institute, London, ON, Canada.,Imaging Research Laboratories, Robarts Research Institute, 1151 Richmond Street North, London, ON, N6A 5B7, Canada.,Department of Medical Imaging and Biophysics, The University of Western Ontario, London, ON, Canada
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17
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Volbers B, Herrmann S, Willfarth W, Lücking H, Kloska SP, Doerfler A, Huttner HB, Kuramatsu JB, Schwab S, Staykov D. Impact of Hypothermia Initiation and Duration on Perihemorrhagic Edema Evolution After Intracerebral Hemorrhage. Stroke 2016; 47:2249-55. [PMID: 27444255 DOI: 10.1161/strokeaha.116.013486] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 06/15/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage (ICH) causes high morbidity and mortality. Recently, perihemorrhagic edema (PHE) has been suggested as an important prognostic factor. Therapeutic hypothermia may be a promising therapeutic option to treat PHE. However, no data exist about the optimal timing and duration of therapeutic hypothermia in ICH. We examined the impact of therapeutic hypothermia timing and duration on PHE evolution. METHODS In this retrospective, single-center, case-control study, we identified patients with ICH treated with mild endovascular hypothermia (target temperature 35°C) from our institutional database. Patients were grouped according to hypothermia initiation (early: days 1-2 and late: days 4-5 after admission) and hypothermia duration (short: 4-8 days and long: 9-15 days). Patients with ICH matched for ICH volume, age, ICH localization, and intraventricular hemorrhage were identified as controls. Relative PHE, temperature, and intracranial pressure course were analyzed. Clinical outcome on day 90 was assessed using the modified Rankin scale (0-3=favorable and 4-6=poor). RESULTS Thirty-three patients with ICH treated with hypothermia and 37 control patients were included. Early hypothermia initiation led to relative PHE decrease between admission and day 3, whereas median relative PHE increased in control patients (-0.05 [interquartile range, -0.4 to 0.07] and 0.07 [interquartile range, -0.07 to 0.26], respectively; P=0.007) and patients with late hypothermia initiation (0.22 [interquartile range 0.12-0.27]; P=0.037). After day 3, relative PHE increased in all groups without difference. Outcome was not different between patients treated with hypothermia and controls. CONCLUSIONS Early hypothermia initiation after ICH onset seems to have an important impact on PHE evolution, whereas our data suggest only limited impact later than day 3 after onset.
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Affiliation(s)
- Bastian Volbers
- From the Neurological Department (B.V., S.H., W.W., H.B.H., J.B.K., S.S., D.S.) and Neuroradiological Department (H.L., S.P.K., A.D.), University of Erlangen-Nuremberg, Germany; and Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria (D.S.).
| | - Sabrina Herrmann
- From the Neurological Department (B.V., S.H., W.W., H.B.H., J.B.K., S.S., D.S.) and Neuroradiological Department (H.L., S.P.K., A.D.), University of Erlangen-Nuremberg, Germany; and Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria (D.S.)
| | - Wolfgang Willfarth
- From the Neurological Department (B.V., S.H., W.W., H.B.H., J.B.K., S.S., D.S.) and Neuroradiological Department (H.L., S.P.K., A.D.), University of Erlangen-Nuremberg, Germany; and Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria (D.S.)
| | - Hannes Lücking
- From the Neurological Department (B.V., S.H., W.W., H.B.H., J.B.K., S.S., D.S.) and Neuroradiological Department (H.L., S.P.K., A.D.), University of Erlangen-Nuremberg, Germany; and Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria (D.S.)
| | - Stephan P Kloska
- From the Neurological Department (B.V., S.H., W.W., H.B.H., J.B.K., S.S., D.S.) and Neuroradiological Department (H.L., S.P.K., A.D.), University of Erlangen-Nuremberg, Germany; and Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria (D.S.)
| | - Arnd Doerfler
- From the Neurological Department (B.V., S.H., W.W., H.B.H., J.B.K., S.S., D.S.) and Neuroradiological Department (H.L., S.P.K., A.D.), University of Erlangen-Nuremberg, Germany; and Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria (D.S.)
| | - Hagen B Huttner
- From the Neurological Department (B.V., S.H., W.W., H.B.H., J.B.K., S.S., D.S.) and Neuroradiological Department (H.L., S.P.K., A.D.), University of Erlangen-Nuremberg, Germany; and Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria (D.S.)
| | - Joji B Kuramatsu
- From the Neurological Department (B.V., S.H., W.W., H.B.H., J.B.K., S.S., D.S.) and Neuroradiological Department (H.L., S.P.K., A.D.), University of Erlangen-Nuremberg, Germany; and Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria (D.S.)
| | - Stefan Schwab
- From the Neurological Department (B.V., S.H., W.W., H.B.H., J.B.K., S.S., D.S.) and Neuroradiological Department (H.L., S.P.K., A.D.), University of Erlangen-Nuremberg, Germany; and Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria (D.S.)
| | - Dimitre Staykov
- From the Neurological Department (B.V., S.H., W.W., H.B.H., J.B.K., S.S., D.S.) and Neuroradiological Department (H.L., S.P.K., A.D.), University of Erlangen-Nuremberg, Germany; and Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria (D.S.)
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Garnacho-Castaño MV, Alva N, Sánchez-Nuño S, Bardallo RG, Palomeque J, Carbonell T. Hypothermia can reverse hepatic oxidative stress damage induced by hypoxia in rats. J Physiol Biochem 2016; 72:615-623. [PMID: 27387890 DOI: 10.1007/s13105-016-0500-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 06/21/2016] [Indexed: 11/26/2022]
Abstract
Our previous findings demonstrated that hypothermia enhances the reduction potential in the liver and helps to maintain the plasmatic antioxidant pool. Here, we aimed to elucidate if hypothermia protects against hypoxia-induced oxidative stress damage in rat liver. Several hepatic markers of oxidative stress were compared in three groups of animals (n = 8 in each group): control normothermic group ventilated with room air and two groups under extreme hypoxia (breathing 10 % O2), one kept at normothermia (HN) (37 °C) and the other under deep hypothermia (HH) (central body temperature of 21-22 °C). Hypoxia in normothermia significantly increased the levels of hepatic nitric oxide, inducible nitric oxide synthase expression, protein oxidation, Carbonilated proteins, advanced oxidation protein products, 4-hydroxynonenal (HNE) protein adducts, and lipid peroxidation when compared to the control group (p < 0.05). However, when hypoxia was induced under hypothermia, results from the oxidative stress biomarker analyses did not differ significantly from those found in the control group. Indeed, 4-HNE protein adduct amounts were significantly lower in the HH versus HN group (p < 0.05). Therefore, hypothermia can mitigate hypoxia-induced oxidative stress damage in rat liver. These effects could help clarify the mechanisms of action of therapeutic hypothermia.
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Affiliation(s)
- Manuel Vicente Garnacho-Castaño
- TecnoCampus Mataró-Maresme, College of Health Sciences, University of Pompeu Fabra, Ernest Lluch, 32 (Porta Laietana), 08302, Mataró-Barcelona, Spain.
- Department of Cell Biology, Physiology and Inmunology, Faculty of Biology, University of Barcelona, 643 Diagonal Ave. (3rd floor), 08028, Barcelona, Spain.
| | - Norma Alva
- Department of Cell Biology, Physiology and Inmunology, Faculty of Biology, University of Barcelona, 643 Diagonal Ave. (3rd floor), 08028, Barcelona, Spain
| | - Sergio Sánchez-Nuño
- Department of Cell Biology, Physiology and Inmunology, Faculty of Biology, University of Barcelona, 643 Diagonal Ave. (3rd floor), 08028, Barcelona, Spain
| | - Raquel G Bardallo
- Department of Cell Biology, Physiology and Inmunology, Faculty of Biology, University of Barcelona, 643 Diagonal Ave. (3rd floor), 08028, Barcelona, Spain
| | - Jesús Palomeque
- Department of Cell Biology, Physiology and Inmunology, Faculty of Biology, University of Barcelona, 643 Diagonal Ave. (3rd floor), 08028, Barcelona, Spain
| | - Teresa Carbonell
- Department of Cell Biology, Physiology and Inmunology, Faculty of Biology, University of Barcelona, 643 Diagonal Ave. (3rd floor), 08028, Barcelona, Spain
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Approaches for Therapeutic Temperature Management. JOURNAL OF INFUSION NURSING 2016; 39:26-9. [DOI: 10.1097/nan.0000000000000146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dietrich WD, Bramlett HM. Therapeutic hypothermia and targeted temperature management in traumatic brain injury: Clinical challenges for successful translation. Brain Res 2015; 1640:94-103. [PMID: 26746342 DOI: 10.1016/j.brainres.2015.12.034] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/16/2015] [Accepted: 12/17/2015] [Indexed: 12/20/2022]
Abstract
The use of therapeutic hypothermia (TH) and targeted temperature management (TTM) for severe traumatic brain injury (TBI) has been tested in a variety of preclinical and clinical situations. Early preclinical studies showed that mild reductions in brain temperature after moderate to severe TBI improved histopathological outcomes and reduced neurological deficits. Investigative studies have also reported that reductions in post-traumatic temperature attenuated multiple secondary injury mechanisms including excitotoxicity, free radical generation, apoptotic cell death, and inflammation. In addition, while elevations in post-traumatic temperature heightened secondary injury mechanisms, the successful implementation of TTM strategies in injured patients to reduce fever burden appear to be beneficial. While TH has been successfully tested in a number of single institutional clinical TBI studies, larger randomized multicenter trials have failed to demonstrate the benefits of therapeutic hypothermia. The use of TH and TTM for treating TBI continues to evolve and a number of factors including patient selection and the timing of the TH appear to be critical in successful trial design. Based on available data, it is apparent that TH and TTM strategies for treating severely injured patients is an important therapeutic consideration that requires more basic and clinical research. Current research involves the evaluation of alternative cooling strategies including pharmacologically-induced hypothermia and the combination of TH or TTM approaches with more selective neuroprotective or reparative treatments. This manuscript summarizes the preclinical and clinical literature emphasizing the importance of brain temperature in modifying secondary injury mechanisms and in improving traumatic outcomes in severely injured patients. This article is part of a Special Issue entitled SI:Brain injury and recovery.
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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, FL, United States.
| | - Helen M Bramlett
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
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Andrews PJD, Sinclair HL, Rodriguez A, Harris BA, Battison CG, Rhodes JKJ, Murray GD. Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. N Engl J Med 2015; 373:2403-12. [PMID: 26444221 DOI: 10.1056/nejmoa1507581] [Citation(s) in RCA: 307] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND In patients with traumatic brain injury, hypothermia can reduce intracranial hypertension. The benefit of hypothermia on functional outcome is unclear. METHODS We randomly assigned adults with an intracranial pressure of more than 20 mm Hg despite stage 1 treatments (including mechanical ventilation and sedation management) to standard care (control group) or hypothermia (32 to 35°C) plus standard care. In the control group, stage 2 treatments (e.g., osmotherapy) were added as needed to control intracranial pressure. In the hypothermia group, stage 2 treatments were added only if hypothermia failed to control intracranial pressure. In both groups, stage 3 treatments (barbiturates and decompressive craniectomy) were used if all stage 2 treatments failed to control intracranial pressure. The primary outcome was the score on the Extended Glasgow Outcome Scale (GOS-E; range, 1 to 8, with lower scores indicating a worse functional outcome) at 6 months. The treatment effect was estimated with ordinal logistic regression adjusted for prespecified prognostic factors and expressed as a common odds ratio (with an odds ratio <1.0 favoring hypothermia). RESULTS We enrolled 387 patients at 47 centers in 18 countries from November 2009 through October 2014, at which time recruitment was suspended owing to safety concerns. Stage 3 treatments were required to control intracranial pressure in 54% of the patients in the control group and in 44% of the patients in the hypothermia group. The adjusted common odds ratio for the GOS-E score was 1.53 (95% confidence interval, 1.02 to 2.30; P=0.04), indicating a worse outcome in the hypothermia group than in the control group. A favorable outcome (GOS-E score of 5 to 8, indicating moderate disability or good recovery) occurred in 26% of the patients in the hypothermia group and in 37% of the patients in the control group (P=0.03). CONCLUSIONS In patients with an intracranial pressure of more than 20 mm Hg after traumatic brain injury, therapeutic hypothermia plus standard care to reduce intracranial pressure did not result in outcomes better than those with standard care alone. (Funded by the National Institute for Health Research Health Technology Assessment program; Current Controlled Trials number, ISRCTN34555414.).
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Affiliation(s)
- Peter J D Andrews
- From the Centre for Clinical Brain Sciences (P.J.D.A.), Department of Anaesthesia, Critical Care, and Pain Medicine (H.L.S., B.A.H., C.G.B., J.K.J.R.), and Centre for Population Health Sciences (A.R., G.D.M.), University of Edinburgh, and Critical Care, Western General Hospital, NHS Lothian (B.A.H., J.K.J.R.) - all in Edinburgh
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Feketa VV, Marrelli SP. Systemic Administration of the TRPV3 Ion Channel Agonist Carvacrol Induces Hypothermia in Conscious Rodents. PLoS One 2015; 10:e0141994. [PMID: 26528923 PMCID: PMC4631363 DOI: 10.1371/journal.pone.0141994] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 10/15/2015] [Indexed: 11/19/2022] Open
Abstract
Therapeutic hypothermia is a promising new strategy for neuroprotection. However, the methods for safe and effective hypothermia induction in conscious patients are lacking. The current study explored the Transient Receptor Potential Vanilloid 3 (TRPV3) channel activation by the agonist carvacrol as a potential hypothermic strategy. It was found that carvacrol lowers core temperature after intraperitoneal and intravenous administration in mice and rats. However, the hypothermic effect at safe doses was modest, while higher intravenous doses of carvacrol induced a pronounced drop in blood pressure and substantial toxicity. Experiments on the mechanism of the hypothermic effect in mice revealed that it was associated with a decrease in whole-body heat generation, but not with a change in cold-seeking behaviors. In addition, the hypothermic effect was lost at cold ambient temperature. Our findings suggest that although TRPV3 agonism induces hypothermia in rodents, it may have a limited potential as a novel pharmacological method for induction of hypothermia in conscious patients due to suboptimal effectiveness and high toxicity.
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Affiliation(s)
- Viktor V. Feketa
- Department of Molecular Physiology and Biophysics Graduate Program, Cardiovascular Sciences Track, Baylor College of Medicine, Houston, Texas, United States of America
| | - Sean P. Marrelli
- Department of Molecular Physiology and Biophysics Graduate Program, Cardiovascular Sciences Track, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas, United States of America
- * E-mail:
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Flynn LM, Rhodes J, Andrews PJ. Therapeutic Hypothermia Reduces Intracranial Pressure and Partial Brain Oxygen Tension in Patients with Severe Traumatic Brain Injury: Preliminary Data from the Eurotherm3235 Trial. Ther Hypothermia Temp Manag 2015; 5:143-51. [PMID: 26060880 PMCID: PMC4575517 DOI: 10.1089/ther.2015.0002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Traumatic brain injury (TBI) is a significant cause of disability and death and a huge economic burden throughout the world. Much of the morbidity associated with TBI is attributed to secondary brain injuries resulting in hypoxia and ischemia after the initial trauma. Intracranial hypertension and decreased partial brain oxygen tension (PbtO2) are targeted as potentially avoidable causes of morbidity. Therapeutic hypothermia (TH) may be an effective intervention to reduce intracranial pressure (ICP), but could also affect cerebral blood flow (CBF). This is a retrospective analysis of prospectively collected data from 17 patients admitted to the Western General Hospital, Edinburgh. Patients with an ICP >20 mmHg refractory to initial therapy were randomized to standard care or standard care and TH (intervention group) titrated between 32°C and 35°C to reduce ICP. ICP and PbtO2 were measured using the Licox system and core temperature was recorded through rectal thermometer. Data were analyzed at the hour before cooling, the first hour at target temperature, 2 consecutive hours at target temperature, and after 6 hours of hypothermia. There was a mean decrease in ICP of 4.3±1.6 mmHg (p<0.04) from 15.7 to 11.4 mmHg, from precooling to the first epoch of hypothermia in the intervention group (n=9) that was not seen in the control group (n=8). A decrease in ICP was maintained throughout all time periods. There was a mean decrease in PbtO2 of 7.8±3.1 mmHg (p<0.05) from 30.2 to 22.4 mmHg, from precooling to stable hypothermia, which was not seen in the control group. This research supports others in demonstrating a decrease in ICP with temperature, which could facilitate a reduction in the use of hyperosmolar agents or other stage II interventions. The decrease in PbtO2 is not below the suggested treatment threshold of 20 mmHg, but might indicate a decrease in CBF.
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Affiliation(s)
- Liam M.C. Flynn
- Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kindgom
| | - Jonathan Rhodes
- Department of Anesthesia and Critical Care, University of Edinburgh and NHS Lothian, Western General Hospital, Edinburgh, United Kingdom
| | - Peter J.D. Andrews
- Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kindgom
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Dingley J, Liu X, Gill H, Smit E, Sabir H, Tooley J, Chakkarapani E, Windsor D, Thoresen M. The feasibility of using a portable xenon delivery device to permit earlier xenon ventilation with therapeutic cooling of neonates during ambulance retrieval. Anesth Analg 2015; 120:1331-6. [PMID: 25794112 DOI: 10.1213/ane.0000000000000693] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Therapeutic hypothermia is the standard of care after perinatal asphyxia. Preclinical studies show 50% xenon improves outcome, if started early. METHODS During a 32-patient study randomized between hypothermia only and hypothermia with xenon, 5 neonates were given xenon during retrieval using a closed-circuit incubator-mounted system. RESULTS Without xenon availability during retrieval, 50% of eligible infants exceeded the 5-hour treatment window. With the transportable system, 100% were recruited. Xenon delivery lasted 55 to 120 minutes, using 174 mL/h (117.5-193.2) (median [interquartile range]), after circuit priming (1300 mL). CONCLUSIONS Xenon delivery during ambulance retrieval was feasible, reduced starting delays, and used very little gas.
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Affiliation(s)
- John Dingley
- From the *College of Medicine, Swansea University, Wales, United Kingdom; †Neonatal Neuroscience, School of Clinical Science, University of Bristol, Bristol, United Kingdom; ‡Neonatal Intensive Care Unit and §Anaesthetic Department, University Hospital Bristol, Bristol, United Kingdom; and the ∥Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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Karnatovskaia LV, Lee AS, Festic E, Kramer CL, Freeman WD. Effect of prolonged therapeutic hypothermia on intracranial pressure, organ function, and hospital outcomes among patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care 2015; 21:451-61. [PMID: 24865270 DOI: 10.1007/s12028-014-9989-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Global cerebral edema (GCE) with subsequent refractory intracranial hypertension complicates some cases of aneurysmal subarachnoid hemorrhage (aSAH), and typically is associated with poorer outcome. Treatment options for refractory intracranial pressure (ICP) cases are limited to decompressive hemicraniectomy (DHC) and targeted temperature management (TTM) with induced hypothermia (32-34 °C). No outcomes comparison between patients treated with either or both forms of refractory ICP therapy exists, and data on the effect of prolonged hypothermia on ICP and organ function among patients with aSAH are limited. METHODS This is a retrospective study of aSAH patients who underwent DHC and/or prolonged hypothermia (greater than 48 h) for refractory ICP (i.e., ICP >20 mmHg after osmotherapy) in the intensive care unit of a single, tertiary-care academic center. RESULTS Nineteen individuals with aSAH underwent TTM with or without DHC; sixteen patients underwent DHC alone. The patients in TTM group were younger (median age 44 years) than the DHC without TTM population (median age 60 years). TTM was started on median day 2 with a median duration of 7 days. There were no significant group differences in survival to discharge (59 % vs. 69 %) or in the mean modified Rankin score on follow-up (3.6 vs. 3.7), despite the TTM group having longer hospital length of stay (24 vs. 19 days, p = 0.03), longer duration of mechanical ventilation (20 vs. 9 days, p = 0.04), a higher cumulative fluid balance (12.8 vs. 5.1 L, p = 0.01), and higher APACHEII scores. The median maximal ICP decreased from 23.5 to 21 mmHg within 24 h of hypothermia initiation. There were no significant differences in other markers of end-organ function (respiratory, hematologic, renal, liver, and cardiac), infection rate, or adverse events between groups. CONCLUSIONS Use of prolonged TTM among aSAH patients with GCE and refractory ICP elevations is associated with a longer duration of mechanical ventilation but is not different in terms of neurological outcomes measured by modified Rankin score or organ function outcomes compared to patients who received DHC alone.
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Affiliation(s)
- Lioudmila V Karnatovskaia
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Davis Building E-7A, Jacksonville, FL, 32224, USA,
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Bakhsheshi MF, Diop M, Morrison LB, St. Lawrence K, Lee TY. Coupling of cerebral blood flow and oxygen consumption during hypothermia in newborn piglets as measured by time-resolved near-infrared spectroscopy: a pilot study. NEUROPHOTONICS 2015; 2:035006. [PMID: 26835481 PMCID: PMC4718069 DOI: 10.1117/1.nph.2.3.035006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/18/2015] [Indexed: 06/05/2023]
Abstract
Hypothermia (HT) is a potent neuroprotective therapy that is now widely used in following neurological emergencies, such as neonatal asphyxia. An important mechanism of HT-induced neuroprotection is attributed to the associated reduction in the cerebral metabolic rate of oxygen ([Formula: see text]). Since cerebral circulation and metabolism are tightly regulated, reduction in [Formula: see text] typically results in decreased cerebral blood flow (CBF); it is only under oxidative stress, e.g., hypoxia-ischemia, that oxygen extraction fraction (OEF) deviates from its basal value, which can lead to cerebral dysfunction. As such, it is critical to measure these key physiological parameters during therapeutic HT. This report investigates a noninvasive method of measuring the coupling of [Formula: see text] and CBF under HT and different anesthetic combinations of propofol/nitrous-oxide ([Formula: see text]) that may be used in clinical practice. Both CBF and [Formula: see text] decreased with decreasing temperature, but the OEF remained unchanged, which indicates a tight coupling of flow and metabolism under different anesthetics and over the mild HT temperature range (38°C to 33°C).
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Affiliation(s)
- Mohammad Fazel Bakhsheshi
- Lawson Health Research Institute, Imaging Program, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada
- Robarts Research Institute, Imaging Research Laboratories, 1151 Richmond Street North, London, Ontario N6A 5B7, Canada
| | - Mamadou Diop
- Lawson Health Research Institute, Imaging Program, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada
- Western University, Department of Medical Biophysics, London, Ontario N6A 5C1, Canada
| | - Laura B. Morrison
- Lawson Health Research Institute, Imaging Program, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada
| | - Keith St. Lawrence
- Lawson Health Research Institute, Imaging Program, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada
- Robarts Research Institute, Imaging Research Laboratories, 1151 Richmond Street North, London, Ontario N6A 5B7, Canada
- Western University, Department of Medical Biophysics, London, Ontario N6A 5C1, Canada
| | - Ting-Yim Lee
- Lawson Health Research Institute, Imaging Program, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada
- Robarts Research Institute, Imaging Research Laboratories, 1151 Richmond Street North, London, Ontario N6A 5B7, Canada
- Western University, Department of Medical Biophysics, London, Ontario N6A 5C1, Canada
- Western University, Department of Medical Imaging, London, Ontario N6A 5W9, Canada
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Rhodes JKJ, Sinclair HL, Battison CG, Harris B, Andrews PJD. Shivering management during therapeutic hypothermia in patients with traumatic brain injury: protocol from the Eurotherm3235 trial. BMC Emerg Med 2015. [PMCID: PMC4480950 DOI: 10.1186/1471-227x-15-s1-a7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Andresen M, Gazmuri JT, Marín A, Regueira T, Rovegno M. Therapeutic hypothermia for acute brain injuries. Scand J Trauma Resusc Emerg Med 2015; 23:42. [PMID: 26043908 PMCID: PMC4456795 DOI: 10.1186/s13049-015-0121-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 04/29/2015] [Indexed: 02/07/2023] Open
Abstract
Therapeutic hypothermia, recently termed target temperature management (TTM), is the cornerstone of neuroprotective strategy. Dating to the pioneer works of Fay, nearly 75 years of basic and clinical evidence support its therapeutic value. Although hypothermia decreases the metabolic rate to restore the supply and demand of O₂, it has other tissue-specific effects, such as decreasing excitotoxicity, limiting inflammation, preventing ATP depletion, reducing free radical production and also intracellular calcium overload to avoid apoptosis. Currently, mild hypothermia (33°C) has become a standard in post-resuscitative care and perinatal asphyxia. However, evidence indicates that hypothermia could be useful in neurologic injuries, such as stroke, subarachnoid hemorrhage and traumatic brain injury. In this review, we discuss the basic and clinical evidence supporting the use of TTM in critical care for acute brain injury that extends beyond care after cardiac arrest, such as for ischemic and hemorrhagic strokes, subarachnoid hemorrhage, and traumatic brain injury. We review the historical perspectives of TTM, provide an overview of the techniques and protocols and the pathophysiologic consequences of hypothermia. In addition, we include our experience of managing patients with acute brain injuries treated using endovascular hypothermia.
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Affiliation(s)
- Max Andresen
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
| | - Jose Tomás Gazmuri
- Hospital de Urgencia Asistencia Pública, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Arnaldo Marín
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
| | - Tomas Regueira
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
| | - Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta, 367, Santiago, Chile.
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Reis C, Wang Y, Akyol O, Ho WM, Ii RA, Stier G, Martin R, Zhang JH. What's New in Traumatic Brain Injury: Update on Tracking, Monitoring and Treatment. Int J Mol Sci 2015; 16:11903-65. [PMID: 26016501 PMCID: PMC4490422 DOI: 10.3390/ijms160611903] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 05/04/2015] [Accepted: 05/06/2015] [Indexed: 12/11/2022] Open
Abstract
Traumatic brain injury (TBI), defined as an alteration in brain functions caused by an external force, is responsible for high morbidity and mortality around the world. It is important to identify and treat TBI victims as early as possible. Tracking and monitoring TBI with neuroimaging technologies, including functional magnetic resonance imaging (fMRI), diffusion tensor imaging (DTI), positron emission tomography (PET), and high definition fiber tracking (HDFT) show increasing sensitivity and specificity. Classical electrophysiological monitoring, together with newly established brain-on-chip, cerebral microdialysis techniques, both benefit TBI. First generation molecular biomarkers, based on genomic and proteomic changes following TBI, have proven effective and economical. It is conceivable that TBI-specific biomarkers will be developed with the combination of systems biology and bioinformation strategies. Advances in treatment of TBI include stem cell-based and nanotechnology-based therapy, physical and pharmaceutical interventions and also new use in TBI for approved drugs which all present favorable promise in preventing and reversing TBI.
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Affiliation(s)
- Cesar Reis
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Yuechun Wang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Physiology, School of Medicine, University of Jinan, Guangzhou 250012, China.
| | - Onat Akyol
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Wing Mann Ho
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Neurosurgery, University Hospital Innsbruck, Tyrol 6020, Austria.
| | - Richard Applegate Ii
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Gary Stier
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Robert Martin
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - John H Zhang
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA.
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van der Jagt M, Haitsma I. An injured brain needs cooling down: no. Intensive Care Med 2015; 41:1129-31. [PMID: 25952828 DOI: 10.1007/s00134-015-3844-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 04/03/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Mathieu van der Jagt
- Department of Intensive Care, Erasmus Medical Center Rotterdam, Room H-611, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands,
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Feketa VV, Marrelli SP. Induction of therapeutic hypothermia by pharmacological modulation of temperature-sensitive TRP channels: theoretical framework and practical considerations. Temperature (Austin) 2015; 2:244-57. [PMID: 27227027 PMCID: PMC4844121 DOI: 10.1080/23328940.2015.1024383] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/25/2015] [Accepted: 02/25/2015] [Indexed: 12/22/2022] Open
Abstract
Therapeutic hypothermia has emerged as a remarkably effective method of neuroprotection from ischemia and is being increasingly used in clinics. Accordingly, it is also a subject of considerable attention from a basic scientific research perspective. One of the fundamental problems, with which current studies are concerned, is the optimal method of inducing hypothermia. This review seeks to provide a broad theoretical framework for approaching this problem, and to discuss how a novel promising strategy of pharmacological modulation of the thermosensitive ion channels fits into this framework. Various physical, anatomical, physiological and molecular aspects of thermoregulation, which provide the foundation for this text, have been comprehensively reviewed and will not be discussed exhaustively here. Instead, the first part of the current review, which may be helpful for a broader readership outside of thermoregulation research, will build on this existing knowledge to outline possible opportunities and research directions aimed at controlling body temperature. The second part, aimed at a more specialist audience, will highlight the conceptual advantages and practical limitations of novel molecular agents targeting thermosensitive Transient Receptor Potential (TRP) channels in achieving this goal. Two particularly promising members of this channel family, namely TRP melastatin 8 (TRPM8) and TRP vanilloid 1 (TRPV1), will be discussed in greater detail.
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Key Words
- DMH, dorso-medial hypothalamus
- MPA, medial preoptic area of hypothalamus
- TRP, Transient Receptor Potential
- TRPA1, Transient Receptor Potential cation channel, subfamily A, member 1
- TRPM8, Transient Receptor Potential cation channel, subfamily M, member 8
- TRPV1, Transient Receptor Potential cation channel, subfamily V, member 1
- TRPV2, Transient Receptor Potential cation channel, subfamily V, member 2
- TRPV3, Transient Receptor Potential cation channel, subfamily V, member 3
- TRPV4, Transient Receptor Potential cation channel, subfamily V, member 4
- ThermoTRPs
- ThermoTRPs, Thermosensitive Transient Receptor Potential cation channels
- body temperature
- core temperature
- pharmacological hypothermia
- physical cooling
- rMR, rostral medullary raphe region
- therapeutic hypothermia
- thermopharmacology
- thermoregulation
- thermosensitive ion channels
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Affiliation(s)
- Viktor V Feketa
- Department of Molecular Physiology and Biophysics Graduate Program; Cardiovascular Sciences Track; Baylor College of Medicine , Houston, TX, USA
| | - Sean P Marrelli
- Department of Molecular Physiology and Biophysics Graduate Program; Cardiovascular Sciences Track; Baylor College of Medicine, Houston, TX, USA; Department of Anesthesiology; Baylor College of Medicine, Houston, TX, USA
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Schiefecker AJ, Beer R, Broessner G, Kofler M, Schmutzhard E, Helbok R. Can Therapeutic Hypothermia Be Guided by Advanced Neuromonitoring in Neurocritical Care Patients? A Review. Ther Hypothermia Temp Manag 2015; 5:126-34. [PMID: 25875898 DOI: 10.1089/ther.2014.0028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The impact of therapeutic hypothermia (TH) on long-term neurological outcome is still controversial. Data on the effects of TH on brain homeostasis are mostly derived from experimental research. Invasive multimodal neuromonitoring techniques may provide additional insight into pathophysiological changes associated with primary or secondary brain injury in humans. In this study we describe the principles of multimodal neuromonitoring and its potential in the clinical setting of TH. We call for more research using multimodal neuromonitoring techniques in patients undergoing TH to optimize cooling and rewarming strategies.
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Affiliation(s)
- Alois Josef Schiefecker
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
| | - Ronny Beer
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
| | - Gregor Broessner
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
| | - Mario Kofler
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
| | - Erich Schmutzhard
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
| | - Raimund Helbok
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
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Vaity C, Al-Subaie N, Cecconi M. Cooling techniques for targeted temperature management post-cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:103. [PMID: 25886948 PMCID: PMC4361155 DOI: 10.1186/s13054-015-0804-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Juratli T, Stephan S, Stephan A, Sobottka S. Akutversorgung des Patienten mit schwerem Schädel-Hirn-Trauma. Anaesthesist 2015; 64:159-74. [DOI: 10.1007/s00101-014-2337-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Polderman K, Lockhart K, Badjatia N. Temperature management in neurological and neurosurgical intensive care units. Ther Hypothermia Temp Manag 2015; 4:62-6. [PMID: 24905837 DOI: 10.1089/ther.2014.1504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Tripathy S, Mahapatra AK. Targeted temperature management in brain protection: An evidence-based review. Indian J Anaesth 2015; 59:9-14. [PMID: 25684807 PMCID: PMC4322114 DOI: 10.4103/0019-5049.149442] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Targeted temperature management (TTM) for neuroprotection involves maintaining the temperature of the brain at predetermined levels by various techniques. It is aimed at avoiding the harmful effects of hyperthermia on the brain and at exploiting the protective effects of lower tissue temperature. There has been an explosion in the use of TTM for neuroprotection in a variety of clinical scenarios apart from the commonly accepted fields of resuscitation and ischaemic, hypoxic encephalopathy. This review briefly discusses the evidence base for TTM. The focus is on various areas of application for neuroprotection, the practical issues pertaining to TTM implementation, the recent data that support it and the present areas of controversy.
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Affiliation(s)
- Swagata Tripathy
- Department of Trauma and Emergency Medicine, Division of Anesthesia and Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Ashok Kumar Mahapatra
- Director and Head, Department of Neurosurgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Matsui T, Yoshida Y, Yanagihara M, Suenaga H. Hypothermia at 35 °C reduces the time-dependent microglial production of pro-inflammatory and anti-inflammatory factors that mediate neuronal cell death. Neurocrit Care 2014; 20:301-10. [PMID: 24072458 DOI: 10.1007/s12028-013-9911-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Therapeutic hypothermia protects neurons after severe brain damage. This effect has been mainly achieved at the core temperatures of 32-34 °C; however, the optimum temperature of therapeutic hypothermia is not fully defined. Here we studied whether hypothermic culture at 35 °C had the same effects on the decrease of time-dependent expression of tumor necrosis factor (TNF)-α, interleukin (IL)-10, and nitric oxide (NO) by stimuli-activated microglia as that at 33 °C, as determined in our previous reports, and whether these factors directly induced neuronal cell death. METHODS We determined the levels of cytokines and NO produced by microglia cultured with adenosine triphosphate (ATP), a toll-like receptor (TLR)2 agonist (N-palmitoyl-S-(2,3-bis(palmitoyloxy)-(2R,S)-propyl)-(R)-cysteinyl-seryl-(lysyl)3-lysine, Pam(3)CSK(4)), or a TLR4 agonist (lipopolysaccharide) under mild hypothermic (33 °C), minimal hypothermic (35 °C), and normothermic (37 °C) conditions. We also determined the viability of rat neuronal pheochromocytoma PC12 cells treated with recombinant TNF-α or IL-10 or (±)-(E)-4-ethyl-2-[(E)-hydroxyimino]-5-nitro-3-hexenamide (NOR3, an NO donor). RESULTS Production of TNF-α, as well as that of IL-10 and NO were decreased by minimal hypothermia at 1.5-6, and 24-48 h, respectively, compared with normothermia, although some effects were diminished as compared with those by mild hypothermia. Exposure to TNF-α, IL-10, and NOR3 caused the death of PC12 cells in a concentration-dependent manner after 24 h. CONCLUSION Hypothermic culture at 35 °C decreased the production of early-phase TNF-α and late-phase IL-10 and NO from ATP- and TLR-activated microglia as observed at 33 °C, albeit with diminished effects. Moreover, these factors caused the death of neuronal cells in a concentration-dependent manner. These results suggest that the attenuation of microglial production of TNF-α, IL-10, and NO by therapeutic hypothermia leads to the inhibition of neuronal cell death. Minimal hypothermia at 35 °C may be sufficient to elicit neuroprotective effect.
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Affiliation(s)
- Tomohiro Matsui
- Department of Laboratory Sciences, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-kogushi, Ube, Yamaguchi, 755-8505, Japan,
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Abstract
Brain injuries caused by stroke are common and costly in human and resource terms. The result of stroke is a cascade of molecular and physiological derangement, cell death, damage and inflammation in the brain. This, together with infection, if present, commonly results in patients having an increased temperature, which is associated with worse outcome. The usual clinical goal in stroke is therefore to reduce temperature to normal, or below normal (hypothermia) to reduce swelling if brain pressure is increased. However, research evidence does not yet conclusively show whether or not cooling patients after stroke improves their longer-term outcome (reduces death and disability). It is possible that complications of cooling outweigh the benefits. Cooling therapy may reduce damage and potentially improve outcome, and head cooling targets the site of injury and may have fewer side effects than systemic cooling, but the evidence base is unclear.
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Affiliation(s)
- Bridget A Harris
- />NHS Lothian and University of Edinburgh, Critical Care Unit, Western General Hospital, Edinburgh, EH4 2XU UK
| | - Peter JD Andrews
- />Department of Anaesthesia and Critical Care, University of Edinburgh and NHS Lothian, Western General Hospital, Edinburgh, EH4 2XU UK
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Rationale, methodology, and implementation of a nationwide multicenter randomized controlled trial of long-term mild hypothermia for severe traumatic brain injury (the LTH-1 trial). Contemp Clin Trials 2014; 40:9-14. [PMID: 25460339 DOI: 10.1016/j.cct.2014.11.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/02/2014] [Accepted: 11/05/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major public health problem recently, however, no intervention showing convincing efficacy. Therapeutic hypothermia with a relatively long duration (more than 48 h), as a promising treatment measure, might improve the patient outcome following severe TBI. METHODS/DESIGN The LTH-1 trial is a prospective, nationwide multicenter, randomized, controlled clinical trial to examine the efficacy and safety of long-term mild hypothermia in adult patients after severe traumatic brain injury. A total of 300 consecutive patients will be recruited from 15 large neurosurgical centers in China. The eligible patient will be randomized to receive either long-term mild hypothermia (34-35 °C) for 5 days, or normothermia (36-37 °C). Additionally, a standardized management protocol will be used in all patients. The primary end point is the neurological outcome 6 months post-injury on the Glasgow Outcome Scale. The secondary outcomes include GOS score at one month post-injury, mortality during six months after injury, length of ICU and hospital stay, intracranial pressure control and Glasgow Coma Scale score during the hospital stay and frequency of complications during the six-month follow-up period. DISCUSSION Long-term hypothermia is recommended by most recent studies and its efficacy urgently needs to be established in randomized controlled settings. The LTH-1 trial, together with other ongoing studies, will present more evidence for optimal use of hypothermia in severe TBI patients.
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Stretti F, Gotti M, Pifferi S, Brandi G, Annoni F, Stocchetti N. Body temperature affects cerebral hemodynamics in acutely brain injured patients: an observational transcranial color-coded duplex sonography study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:552. [PMID: 25311035 PMCID: PMC4213544 DOI: 10.1186/s13054-014-0552-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 09/23/2014] [Indexed: 11/18/2022]
Abstract
Introduction Temperature changes are common in patients in a neurosurgical intensive care unit (NICU): fever is frequent among severe cases and hypothermia is used after cardiac arrest and is currently being tested in clinical trials to lower intracranial pressure (ICP). This study investigated cerebral hemodynamics when body temperature varies in acute brain injured patients. Methods We enrolled 26 patients, 14 with acute brain injury who developed fever and were given antipyretic therapy (defervescence group) and 12 who underwent an intracranial neurosurgical procedure and developed hypothermia in the operating room; once admitted to the NICU, still under anesthesia, they were re-warmed before waking (re-warming group). We measured cerebral blood flow velocity (CBF-V) and pulsatility index (PI) at the middle cerebral artery using transcranial color-coded duplex sonography (TCCDS). Results In the defervescence group mean CBF-V decreased from 75 ± 26 (95% CI 65 to 85) to 70 ± 22 cm/s (95% CI 61 to 79) (P = 0.04); the PI also fell, from 1.36 ± 0.33 (95% CI 1.23 to 1.50) to 1.16 ± 0.26 (95% CI 1.05 to 1.26) (P = 0.0005). In the subset of patients with ICP monitoring, ICP dropped from 16 ± 8 to 12 ± 6 mmHg (P = 0.003). In the re-warming group mean CBF-V increased from 36 ± 10 (95% CI 31 to 41) to 39 ± 13 (95% CI 33 to 45) cm/s (P = 0.04); the PI rose from 0.98 ± 0.14 (95% CI 0.91 to 1.04) to 1.09 ± 0.22 (95% CI 0.98 to 1.19) (P = 0.02). Conclusions Body temperature affects cerebral hemodynamics as evaluated by TCCDS; when temperature rises, CBF-V increases in parallel, and viceversa when temperature decreases. When cerebral compliance is reduced and compensation mechanisms are exhausted, even modest temperature changes can greatly affect ICP.
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Sanfilippo F, Santonocito C, Veenith T, Astuto M, Maybauer MO. The Role of Neuromuscular Blockade in Patients with Traumatic Brain Injury: A Systematic Review. Neurocrit Care 2014; 22:325-34. [DOI: 10.1007/s12028-014-0061-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Kochanek PM, Erlinge D, Polderman KH, Windsor J. Developing cooling strategies targeting the heart in adults and children. Ther Hypothermia Temp Manag 2014; 2:157-61. [PMID: 24716488 DOI: 10.1089/ther.2012.1518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Patrick M Kochanek
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
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Karnatovskaia LV, Wartenberg KE, Freeman WD. Therapeutic hypothermia for neuroprotection: history, mechanisms, risks, and clinical applications. Neurohospitalist 2014; 4:153-63. [PMID: 24982721 DOI: 10.1177/1941874413519802] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The earliest recorded application of therapeutic hypothermia in medicine spans about 5000 years; however, its use has become widespread since 2002, following the demonstration of both safety and efficacy of regimens requiring only a mild (32°C-35°C) degree of cooling after cardiac arrest. We review the mechanisms by which hypothermia confers neuroprotection as well as its physiological effects by body system and its associated risks. With regard to clinical applications, we present evidence on the role of hypothermia in traumatic brain injury, intracranial pressure elevation, stroke, subarachnoid hemorrhage, spinal cord injury, hepatic encephalopathy, and neonatal peripartum encephalopathy. Based on the current knowledge and areas undergoing or in need of further exploration, we feel that therapeutic hypothermia holds promise in the treatment of patients with various forms of neurologic injury; however, additional quality studies are needed before its true role is fully known.
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Affiliation(s)
| | - Katja E Wartenberg
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Germany
| | - William D Freeman
- Departments of Neurology, Neurosurgery, Critical Care, Mayo Clinic, Jacksonville, FL, USA
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Abstracts from the 3rd innsbruck targeted temperature management symposium-a multidisciplinary conference september 21, 2013 vienna, austria. Ther Hypothermia Temp Manag 2014; 3:A1-A14. [PMID: 24834952 DOI: 10.1089/ther.2013.1517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Crossley S, Reid J, McLatchie R, Hayton J, Clark C, MacDougall M, Andrews PJD. A systematic review of therapeutic hypothermia for adult patients following traumatic brain injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R75. [PMID: 24742169 PMCID: PMC4056614 DOI: 10.1186/cc13835] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 04/03/2014] [Indexed: 12/16/2022]
Abstract
Introduction Research into therapeutic hypothermia following traumatic brain injury has been characterised by small trials of poor methodological quality, producing variable results. The Cochrane review, published in 2009, now requires updating. The aim of this systematic review is to assess the effectiveness of the application of therapeutic hypothermia to reduce death and disability when administered to adult patients who have been admitted to hospital following traumatic brain injury. Methods Two authors extracted data from each trial. Unless stated in the trial report, relative risks and 95% confidence intervals (CIs) were calculated for each trial. We considered P < 0 · 05 to be statistically significant. We combined data from all trials to estimate the pooled risk ratio (RR) with 95% confidence intervals for death, unfavourable outcome, and pneumonia. All statistical analyses were performed using RevMan 5.1 (Cochrane IMS, Oxford, UK) and Stata (Intercooled Version 12.0, StataCorp LP). Pooled RRs were calculated using the Mantel-Haenszel estimator. The random effects model of DerSimonian and Laird was used to estimate variances for the Mantel-Haenszel and inverse variance estimators. Results Twenty studies are included in the review, while 18 provided mortality data. When the results of 18 trials that evaluated mortality as one of the outcomes were statistically aggregated, therapeutic hypothermia was associated with a significant reduction in mortality and a significant reduction in poor outcome. There was a lack of statistical evidence for an association between use of therapeutic hypothermia and increased onset of new pneumonia. Conclusions In contrast to previous reviews, this systematic review found some evidence to suggest that therapeutic hypothermia may be of benefit in the treatment of traumatic brain injury. The majority of trials were of low quality, with unclear allocation concealment. Low quality trials may overestimate the effectiveness of hypothermia treatment versus standard care. There remains a need for more, high quality, randomised control trials of therapeutic hypothermia after traumatic brain injury. PROSPERO Systematic Review Registration Number 2012:
CRD42012002449.
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Søreide K. Clinical and translational aspects of hypothermia in major trauma patients: from pathophysiology to prevention, prognosis and potential preservation. Injury 2014; 45:647-54. [PMID: 23352151 DOI: 10.1016/j.injury.2012.12.027] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Revised: 12/23/2012] [Accepted: 12/28/2012] [Indexed: 02/02/2023]
Abstract
The human body strives at maintaining homeostasis within fairly tight regulated mechanisms that control vital regulators such as core body temperature, mechanisms of metabolism and endocrine function. While a wide range of medical conditions can influence thermoregulation the most common source of temperature loss in trauma patients includes: exposure (environmental, as well as cavitary), the administration of i.v. fluids, and anaesthesia/loss of shivering mechanisms, and blood loss per se. Loss of temperature can be classified either according to the aetiology (i.e. accidental/spontaneous versus trauma/haemorrhage-induced temperature loss), or according to an unintended, accidental induction in contrast to a medically intended therapeutic hypothermia. Hypothermia occurs infrequently (prevalence<10% of all injured), but more often (30-50%) in the severely injured. Hypothermia usually come together with and may aggravate acidosis and coagulopathy (the "lethal triad of trauma"), which again may be associated with a high mortality. However, recent studies disagree in the independent predictive role of hypothermia and mortality. Prevention of hypothermia is imperative through all phases of trauma care and must be an interest among all team members. Hypothermia in the trauma setting has attracted focus in the past from a pathophysiological, preventive and prognostic perspective; yet recent focus has shifted towards the potential for using hypothermia for pre-emptive and cellular protective purposes. This paper gives a brief update on some of the clinically relevant aspects of hypothermia in the injured patient.
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Affiliation(s)
- Kjetil Søreide
- Department of Surgery, Stavanger University Hospital, Stavanger, Norway; Institute of Health and Medicine, University of Stavanger, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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Chowdhury T, Kowalski S, Arabi Y, Dash HH. Specific intensive care management of patients with traumatic brain injury: Present and future. Saudi J Anaesth 2014; 8:268-75. [PMID: 24843345 PMCID: PMC4024689 DOI: 10.4103/1658-354x.130746] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Traumatic brain injury (TBI) is a major global problem and affects approximately 10 million peoples annually; therefore has a substantial impact on the health-care system throughout the world. In this article, we have summarized various aspects of specific intensive care management in patients with TBI including the emerging evidence mainly after the Brain Trauma Foundation (BTF) 2007 and also highlighted the scope of the future therapies. This review has involved the relevant clinical trials and reviews (from 1 January 2007 to 31 March 2013), which specifically discussed about the topic. Though, BTF guideline based management strategies could provide standardized protocols for the management of patients with TBI and have some promising effects on mortality and morbidity; there is still need of inclusion of many suggestions based on various published after 2007. The main focus of majority of these trials remained to prevent or to treat the secondary brain injury. The future therapy will be directed to treat injured neurons and may benefit the outcome. There is also urgent need to develop some good prognostic indicators as well.
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Affiliation(s)
- Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, Section of Critical Care, University of Manitoba, Winnipeg, Canada
| | - Stephen Kowalski
- Department of Anesthesiology and Perioperative Medicine, Section of Critical Care, University of Manitoba, Winnipeg, Canada
| | - Yaseen Arabi
- Department of Intensive Care, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia
| | - Hari Hara Dash
- Department of Anesthesia and Perioperative Medicine, Fortis Memorial Research Institute, Gurgaon, Haryana, India
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Povlishock J, Yokobori S, Kuroda Y, Polderman K. Cooling Strategies Targeting Trauma. Ther Hypothermia Temp Manag 2014; 4:3-7. [PMID: 24660098 DOI: 10.1089/ther.2014.1502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John Povlishock
- Department of Anatomy and Neurobiology, Virginia Commonwealth University , Richmond, Virginia
| | - Shoji Yokobori
- Department of Neurological Surgery, University of Miami Miller School of Medicine , Miami, Florida
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine , Kagawa, Japan
| | - Kees Polderman
- Department of Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
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Li LM, Menon DK, Janowitz T. Cross-sectional analysis of data from the U.S. clinical trials database reveals poor translational clinical trial effort for traumatic brain injury, compared with stroke. PLoS One 2014; 9:e84336. [PMID: 24416218 PMCID: PMC3885561 DOI: 10.1371/journal.pone.0084336] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 11/14/2013] [Indexed: 02/02/2023] Open
Abstract
Traumatic brain injury (TBI) is an important public health problem, comparable to stroke in incidence and prevalence. Few interventions have proven efficacy in TBI, and clinical trials are, therefore, necessary to advance management in TBI. We describe the current clinical trial landscape in traumatic brain injury and compare it with the trial efforts for stroke. For this, we analysed all stroke and TBI studies registered on the US Clinical Trials (www.clinicaltrials.gov) database over a 10-year period (01/01/2000 to 01/31/2013). This methodology has been previously used to analyse clinical trial efforts in other specialties. We describe the research profile in each area: total number of studies, total number of participants and change in number of research studies over time. We also analysed key study characteristics, such as enrolment number and scope of recruitment. We found a mismatch between relative public health burden and relative research effort in each disease. Despite TBI having comparable prevalence and higher incidence than stroke, it has around one fifth of the number of clinical trials and participant recruitment. Both stroke and TBI have experienced an increase in the number of studies over the examined time period, but the rate of growth for TBI is one third that for stroke. Small-scale (<1000 participants per trial) and single centre studies form the majority of clinical trials in both stroke and TBI, with TBI having significantly fewer studies with international recruitment. We discuss the consequences of these findings and how the situation might be improved. A sustained research effort, entailing increased international collaboration and rethinking the methodology of running clinical trials, is required in order to improve outcomes after traumatic brain injury.
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Affiliation(s)
- Lucia M. Li
- Division of Medicine, Imperial College London, London, United Kingdom
| | - David K. Menon
- Division of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Tobias Janowitz
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Oxidative stress and antioxidant activity in hypothermia and rewarming: can RONS modulate the beneficial effects of therapeutic hypothermia? OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2013; 2013:957054. [PMID: 24363826 PMCID: PMC3865646 DOI: 10.1155/2013/957054] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 10/21/2013] [Indexed: 12/12/2022]
Abstract
Hypothermia is a condition in which core temperature drops below the level necessary to maintain bodily functions. The decrease in temperature may disrupt some physiological systems of the body, including alterations in microcirculation and reduction of oxygen supply to tissues. The lack of oxygen can induce the generation of reactive oxygen and nitrogen free radicals (RONS), followed by oxidative stress, and finally, apoptosis and/or necrosis. Furthermore, since the hypothermia is inevitably followed by a rewarming process, we should also consider its effects. Despite hypothermia and rewarming inducing injury, many benefits of hypothermia have been demonstrated when used to preserve brain, cardiac, hepatic, and intestinal function against ischemic injury. This review gives an overview of the effects of hypothermia and rewarming on the oxidant/antioxidant balance and provides hypothesis for the role of reactive oxygen species in therapeutic hypothermia.
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