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Lin V, Tian C, Wahlster S, Castillo-Pinto C, Mainali S, Johnson NJ. Temperature Control in Acute Brain Injury: An Update. Semin Neurol 2024; 44:308-323. [PMID: 38593854 DOI: 10.1055/s-0044-1785647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Temperature control in severe acute brain injury (SABI) is a key component of acute management. This manuscript delves into the complex role of temperature management in SABI, encompassing conditions like traumatic brain injury (TBI), acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (aSAH), and hypoxemic/ischemic brain injury following cardiac arrest. Fever is a common complication in SABI and is linked to worse neurological outcomes due to increased inflammatory responses and intracranial pressure (ICP). Temperature management, particularly hypothermic temperature control (HTC), appears to mitigate these adverse effects primarily by reducing cerebral metabolic demand and dampening inflammatory pathways. However, the effectiveness of HTC varies across different SABI conditions. In the context of post-cardiac arrest, the impact of HTC on neurological outcomes has shown inconsistent results. In cases of TBI, HTC seems promising for reducing ICP, but its influence on long-term outcomes remains uncertain. For AIS, clinical trials have yet to conclusively demonstrate the benefits of HTC, despite encouraging preclinical evidence. This variability in efficacy is also observed in ICH, aSAH, bacterial meningitis, and status epilepticus. In pediatric and neonatal populations, while HTC shows significant benefits in hypoxic-ischemic encephalopathy, its effectiveness in other brain injuries is mixed. Although the theoretical basis for employing temperature control, especially HTC, is strong, the clinical outcomes differ among various SABI subtypes. The current consensus indicates that fever prevention is beneficial across the board, but the application and effectiveness of HTC are more nuanced, underscoring the need for further research to establish optimal temperature management strategies. Here we provide an overview of the clinical evidence surrounding the use of temperature control in various types of SABI.
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Affiliation(s)
- Victor Lin
- Department of Neurology, University of Washington, Seattle, Washington
| | - Cindy Tian
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, Washington
- Department of Neurosurgery, University of Washington, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Binda DD, Baker MB, Varghese S, Wang J, Badenes R, Bilotta F, Nozari A. Targeted Temperature Management for Patients with Acute Ischemic Stroke: A Literature Review. J Clin Med 2024; 13:586. [PMID: 38276093 PMCID: PMC10816923 DOI: 10.3390/jcm13020586] [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: 12/16/2023] [Revised: 01/03/2024] [Accepted: 01/11/2024] [Indexed: 01/27/2024] Open
Abstract
Despite significant advances in medical imaging, thrombolytic therapy, and mechanical thrombectomy, acute ischemic strokes (AIS) remain a major cause of mortality and morbidity globally. Targeted temperature management (TTM) has emerged as a potential therapeutic intervention, aiming to mitigate neuronal damage and improve outcomes. This literature review examines the efficacy and challenges of TTM in the context of an AIS. A comprehensive literature search was conducted using databases such as PubMed, Cochrane, Web of Science, and Google Scholar. Studies were selected based on relevance and quality. We identified key factors influencing the effectiveness of TTM such as its timing, depth and duration, and method of application. The review also highlighted challenges associated with TTM, including increased pneumonia rates. The target temperature range was typically between 32 and 36 °C, with the duration of cooling from 24 to 72 h. Early initiation of TTM was associated with better outcomes, with optimal results observed when TTM was started within the first 6 h post-stroke. Emerging evidence indicates that TTM shows considerable potential as an adjunctive treatment for AIS when implemented promptly and with precision, thereby potentially mitigating neuronal damage and enhancing overall patient outcomes. However, its application is complex and requires the careful consideration of various factors.
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Affiliation(s)
- Dhanesh D. Binda
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Maxwell B. Baker
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Shama Varghese
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Jennifer Wang
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
| | - Rafael Badenes
- Department Anesthesiology, Surgical-Trauma Intensive Care and Pain Clinic, Hospital Clínic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Federico Bilotta
- Department of Anaesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I Teaching Hospital, Sapienza University of Rome, 00185 Rome, Italy;
| | - Ala Nozari
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA; (D.D.B.); (M.B.B.); (S.V.); (J.W.); (A.N.)
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Cujkevic-Plecko N, Rodriguez A, Anderson T, Rhodes J. Targeted temperature management and P btO 2 in traumatic brain injury. BRAIN & SPINE 2023; 3:102704. [PMID: 38105803 PMCID: PMC10724196 DOI: 10.1016/j.bas.2023.102704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/06/2023] [Accepted: 10/29/2023] [Indexed: 12/19/2023]
Abstract
Introduction Targeted Temperature Management (TTM) to normothermia is widely used in traumatic brain injury (TBI). We investigated the effects to of TTM to normothermia patients with TBI (GCS≤12) monitored with multimodality monitoring, to better understand the physiological consequences of this intervention. Research question In TBI patients cooled to normothermia and in which brain oxygenation deteriorates, are there changes in physiological parameters which are pertinent to brain oxygenation? Material and method 102 TBI patients with continuous recordings of intracranial pressure (ICP) and brain oxygen tension (PbtO2) were studied retrospectively. Non-continuous arterial carbon dioxide (PaCO2) and oxygen (PaO2) tensions, and core body temperature (Tc) were added. PaO2 and PaCO2 were also corrected for Tc. Transitions from elevated Tc to normothermia were identified in 39 patients. The 8 h pre and post the transition to normothermia were compared. Data is given as median [IQR] or mean (SD). Results Overall, normothermia reduced ICP (12 [9-18] -11 [8-17] mmHg, p < 0.009) and Tcore (38.3 [0.3]-36.9 [0.4] oC, p < 0.001), but not PbtO2 (23.3 [16.6]-24.4 [17.2-28.7] mmHg, NS). Normothermia was associated with a fall in PbtO2 in 18 patients (24.5 [9.3] -20.8 [7.6] mmHg). Only in those with a fall in PbtO2 with cooling did ICP (15 [10.8-18.5] -12 [7.8-17.3] mmHg, p = 0.002), and temperature corrected PaCO2 (5.3 [0.5]- 4.9 [0.8] kPa, p = 0.001) decrease. Discussion and conclusion A reduction in PbtO2 was only present in the subgroup of patients with a fall in temperature corrected PaCO2 with cooling. This suggests that even modest temperature changes could result in occult hyperventilation in some patients. pH stat correction of ventilation may be an important factor to consider in future TTM protocols.
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Affiliation(s)
| | | | - T. Anderson
- University of Edinburgh Department of Anaesthesia, Critical Care and Pain Medicine & NHS Lothian, UK
| | - J. Rhodes
- University of Edinburgh Department of Anaesthesia, Critical Care and Pain Medicine & NHS Lothian, UK
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Li X, Helleringer R, Martucci LL, Dallérac G, Cancela JM, Galante M. Low Temperature Delays the Effects of Ischemia in Bergmann Glia and in Cerebellar Tissue Swelling. Biomedicines 2023; 11:biomedicines11051363. [PMID: 37239034 DOI: 10.3390/biomedicines11051363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/23/2023] [Accepted: 04/29/2023] [Indexed: 05/28/2023] Open
Abstract
Cerebral ischemia results in oxygen and glucose deprivation that most commonly occurs after a reduction or interruption in the blood supply to the brain. The consequences of cerebral ischemia are complex and involve the loss of metabolic ATP, excessive K+ and glutamate accumulation in the extracellular space, electrolyte imbalance, and brain edema formation. So far, several treatments have been proposed to alleviate ischemic damage, yet few are effective. Here, we focused on the neuroprotective role of lowering the temperature in ischemia mimicked by an episode of oxygen and glucose deprivation (OGD) in mouse cerebellar slices. Our results suggest that lowering the temperature of the extracellular 'milieu' delays both the increases in [K+]e and tissue swelling, two dreaded consequences of cerebellar ischemia. Moreover, radial glial cells (Bergmann glia) display morphological changes and membrane depolarizations that are markedly impeded by lowering the temperature. Overall, in this model of cerebellar ischemia, hypothermia reduces the deleterious homeostatic changes regulated by Bergmann glia.
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Affiliation(s)
- Xia Li
- Institut des Neurosciences Paris-Saclay, CNRS, Université Paris-Saclay, 91400 Saclay, France
| | - Romain Helleringer
- Institut des Neurosciences Paris-Saclay, CNRS, Université Paris-Saclay, 91400 Saclay, France
| | - Lora L Martucci
- Institut des Neurosciences Paris-Saclay, CNRS, Université Paris-Saclay, 91400 Saclay, France
| | - Glenn Dallérac
- Institut des Neurosciences Paris-Saclay, CNRS, Université Paris-Saclay, 91400 Saclay, France
| | - José-Manuel Cancela
- Institut des Neurosciences Paris-Saclay, CNRS, Université Paris-Saclay, 91400 Saclay, France
| | - Micaela Galante
- Institut des Neurosciences Paris-Saclay, CNRS, Université Paris-Saclay, 91400 Saclay, France
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Angus SA, Henderson WR, Banoei MM, Molgat‐Seon Y, Peters CM, Parmar HR, Griesdale DEG, Sekhon M, Sheel AW, Winston BW, Dominelli PB. Therapeutic hypothermia attenuates physiologic, histologic, and metabolomic markers of injury in a porcine model of acute respiratory distress syndrome. Physiol Rep 2022; 10:e15286. [PMID: 35510328 PMCID: PMC9069168 DOI: 10.14814/phy2.15286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/29/2022] [Accepted: 04/02/2022] [Indexed: 06/14/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a lung injury characterized by noncardiogenic pulmonary edema and hypoxic respiratory failure. The purpose of this study was to investigate the effects of therapeutic hypothermia on short-term experimental ARDS. Twenty adult female Yorkshire pigs were divided into four groups (n = 5 each): normothermic control (C), normothermic injured (I), hypothermic control (HC), and hypothermic injured (HI). Acute respiratory distress syndrome was induced experimentally via intrapulmonary injection of oleic acid. Target core temperature was achieved in the HI group within 1 h of injury induction. Cardiorespiratory, histologic, cytokine, and metabolomic data were collected on all animals prior to and following injury/sham. All data were collected for approximately 12 h from the beginning of the study until euthanasia. Therapeutic hypothermia reduced injury in the HI compared to the I group (histological injury score = 0.51 ± 0.18 vs. 0.76 ± 0.06; p = 0.02) with no change in gas exchange. All groups expressed distinct phenotypes, with a reduction in pro-inflammatory metabolites, an increase in anti-inflammatory metabolites, and a reduction in inflammatory cytokines observed in the HI group compared to the I group. Changes to respiratory system mechanics in the injured groups were due to increases in lung elastance (E) and resistance (R) (ΔE from pre-injury = 46 ± 14 cmH2 O L-1 , p < 0.0001; ΔR from pre-injury: 3 ± 2 cmH2 O L-1 s- , p = 0.30) rather than changes to the chest wall (ΔE from pre-injury: 0.7 ± 1.6 cmH2 O L-1 , p = 0.99; ΔR from pre-injury: 0.6 ± 0.1 cmH2 O L-1 s- , p = 0.01). Both control groups had no change in respiratory mechanics. In conclusion, therapeutic hypothermia can reduce markers of injury and inflammation associated with experimentally induced short-term ARDS.
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Affiliation(s)
- Sarah A. Angus
- Department of KinesiologyUniversity of WaterlooWaterlooOntarioCanada
| | - William R. Henderson
- Division of Critical Care MedicineDepartment of MedicineFaculty of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Mohammad M. Banoei
- Department of Critical Care MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Yannick Molgat‐Seon
- Department Kinesiology and Applied HealthUniversity of WinnipegWinnipegManitobaCanada
| | - Carli M. Peters
- School of KinesiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Hanna R. Parmar
- School of KinesiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Donald E. G. Griesdale
- Division of Critical Care MedicineDepartment of MedicineFaculty of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Department of AnesthesiologyPharmacology & TherapeuticsUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Mypinder Sekhon
- Division of Critical Care MedicineDepartment of MedicineFaculty of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Andrew William Sheel
- School of KinesiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Brent W. Winston
- Department of Critical Care MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Departments of Medicine and Biochemistry & Molecular BiologyUniversity of CalgaryCalgaryAlbertaCanada
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Zhao XJ, Zhu HY, Wang XL, Lu XW, Pan CL, Xu L, Liu X, Xu N, Zhang ZY. Oridonin ameliorates traumatic brain injury-induced neurological damage by improving mitochondrial function and antioxidant capacity and suppressing neuroinflammation through the Nrf2 pathway. J Neurotrauma 2022; 39:530-543. [PMID: 35102762 DOI: 10.1089/neu.2021.0466] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Traumatic brain injury (TBI) is a global public health concern, and few effective treatments for its delayed damages are available. Oridonin (Ori) has been recently reported to show a promising neuroprotective efficacy, but its potential therapeutic effect on TBI has not been thoroughly elucidated. TBI mouse models were established and treated with Ori or vehicle 30 minutes post-operation and every 24 hours since then. Impairments in cognitive and motor function and neuropathological changes were evaluated and compared. The therapeutic efficacy and mechanisms of action of Ori were further investigated using animal tissues and cell cultures. Ori restored motor function and cognition following TBI-induced impairment and exerted neuroprotective effects by reducing cerebral edema and cortical lesion volume. Ori increased neuronal survival, ameliorating gliosis and the accumulation of macrophages after injury. It suppressed the increased production of reactive oxygen species, lipid peroxide, and malondialdehyde; and reversed the decrease of mitochondrial membrane potential and adenosine triphosphate content, which was also identified in oxidatively stressed neuronal cultures. Furthermore, Ori inhibited the expression of NLRP3 inflammasome proteins and NLRP3-dependent cytokine IL-1β that can be induced by oxidative stress following TBI. Regarding underlying mechanisms, Ori significantly enhanced expression of key proteins of the Nrf2/HO-1 pathway. Our results demonstrated that Ori effectively improved functional impairments and neuropathological changes in TBI animals. By activating the Nrf2 pathway, it improved mitochondrial function and antioxidant capacity, and suppressed the neuroinflammation induced by oxidative stress. The results therefore suggest Ori as a potent candidate for treating neurological damage after TBI.
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Affiliation(s)
- Xiao-Jing Zhao
- Nanjing Medical University, 12461, School of Basic Medical Sciences, Nanjing, Jiangsu, China.,The Affiliated Jiangning Hospital of Nanjing Medical University, 579164, Department of Pathology, Nanjing, Jiangsu, China;
| | - Hai-Yan Zhu
- Nanjing Medical University, 12461, School of Basic Medical Sciences, Nanjing, Jiangsu, China;
| | - Xiao-Liang Wang
- Nanjing First Hospital, 385685, Department of Anesthesiology, Nangjing, Jiangsu, China;
| | - Xiao-Wei Lu
- Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, 74734, Department of Geriatrics, Nanjing, Jiangsu, China;
| | - Cai-Long Pan
- Nanjing Medical University, 12461, School of Basic Medical Sciences, Nanjing, Jiangsu, China;
| | - Lu Xu
- Nanjing Medical University, 12461, School of Basic Medical Sciences, Nanjing, Jiangsu, China.,Nanjing Medical University, 12461, Key Laboratory of Antibody Technique of Ministry of Health, Nanjing, Jiangsu, China;
| | - Xue Liu
- Nanjing Medical University, 12461, School of Basic Medical Sciences, Nanjing, Jiangsu, China;
| | - Ning Xu
- Nanjing Medical University, 12461, School of Basic Medical Sciences, Nanjing, Jiangsu, China.,Nanjing Medical University, 12461, Key Laboratory of Antibody Technique of Ministry of Health, Nanjing, Jiangsu, China;
| | - Zhi-Yuan Zhang
- Nanjing Medical University, 12461, School of Basic Medical Sciences, Nanjing, Jiangsu, China.,Nanjing Medical University, 12461, Key Laboratory of Antibody Technique of Ministry of Health, Nanjing, Jiangsu, China;
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Hodoodi F, Allah-Tavakoli M, Tajik F, Fatemi I, Moghadam Ahmadi A. The effect of head cooling and remote ischemic conditioning on patients with traumatic brain injury. iScience 2021; 24:102472. [PMID: 34169235 PMCID: PMC8207229 DOI: 10.1016/j.isci.2021.102472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/12/2020] [Accepted: 04/22/2021] [Indexed: 11/17/2022] Open
Abstract
Cerebral impairment caused by an external force to the head is known as traumatic brain injury (TBI). The aim of this study was to determine the role of local hypothermia and remote ischemic conditioning (RIC) on oxidative stress, inflammatory response after TBI, and other involved variables. The present study is a clinical trial on 84 patients with TBI who were divided into 4 groups. The head cooling for 1.5 to 6 hr was performed in the first three days after TBI. RIC intervention was performed within the golden time after TBI in the form of four 5-min cycles with full cuff and 5 min of emptying of cuff. The group receiving the head cooling technique recovered better than the group receiving the RIC technique. Generally, combination of the two interventions of head cooling and RIC techniques is more effective on the improvement of clinical status of patients than each separate technique. The effect of the head cooling method in controlling secondary injury in patients with TBI. The effect of the RIC method in controlling secondary injury in patients with TBI. Comparison of two interventions of head cooling and RIC. Evaluation of clinical and paraclinical parameters.
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Affiliation(s)
- Fardin Hodoodi
- Department of Physiology and Pharmacology, Schoole of Medicine, Rafsanjan University of Medical Science, Rafsanjan, Iran
| | - Mohammad Allah-Tavakoli
- Department of Physiology and Pharmacology, Schoole of Medicine, Rafsanjan University of Medical Science, Rafsanjan, Iran
- Physiology-pharmacology Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Farzad Tajik
- Department of Clinical Research Sciences, Department of Medicine, Rafsanjan University of Medical Science, Rafsanjan, Iran
- Department of Neurology, Department of Medicine, Rafsanjan University of Medical Science, Rafsanjan, Iran
| | - Iman Fatemi
- Research Center of Tropical and Infectious Diseases, Kerman University of Medical Sciences, Kerman, Iran
| | - Amir Moghadam Ahmadi
- Department of Neurology, Department of Medicine, Rafsanjan University of Medical Science, Rafsanjan, Iran
- Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
- Corresponding author
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Abstract
This article introduces the basic concepts of intracranial physiology and pressure dynamics. It also includes discussion of signs and symptoms and examination and radiographic findings of patients with acute cerebral herniation as a result of increased as well as decreased intracranial pressure. Current best practices regarding medical and surgical treatments and approaches to management of intracranial hypertension as well as future directions are reviewed. Lastly, there is discussion of some of the implications of critical medical illness (sepsis, liver failure, and renal failure) and treatments thereof on causation or worsening of cerebral edema, intracranial hypertension, and cerebral herniation.
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Affiliation(s)
- Aleksey Tadevosyan
- Department of Neurology, Tufts University School of Medicine, Beth Israel Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
| | - Joshua Kornbluth
- Department of Neurology, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Box#314, Boston, MA 02111, USA
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Vermeersch V, Huet O. Prophylactic hypothermia for traumatic brain injury patients: It is not cool to be cooled. Anaesth Crit Care Pain Med 2019; 38:97-98. [PMID: 30763725 DOI: 10.1016/j.accpm.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Véronique Vermeersch
- Department of anaesthesia and intensive care medicine, CHRU La Cavale Blanche, Brest, France; UFR de médecine, Université de Bretagne occidentale, Brest, France
| | - Olivier Huet
- Department of anaesthesia and intensive care medicine, CHRU La Cavale Blanche, Brest, France; UFR de médecine, Université de Bretagne occidentale, Brest, France; ANZIC research centre, Monash University, Melbourne, Victoria, Australia.
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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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Neuroprotective Effects of Nasopharyngeal Perfluorochemical Cooling in a Rat Model of Subarachnoid Hemorrhage. World Neurosurg 2018; 121:e481-e492. [PMID: 30267945 DOI: 10.1016/j.wneu.2018.09.142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 09/16/2018] [Accepted: 09/18/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Subarachnoid hemorrhage (SAH) frequently results in severe morbidity, even mortality. Hypothermia is known to have a neuroprotective effect in ischemic injuries. The aim of this study was to determine whether nasopharyngeal (NP) perfluorochemical (PFC) cooling could be used in a rat model of SAH model for neuroprotection. METHODS SAH was induced in 16 male Sprague-Dawley rats by cisterna magna injection of 0.3 mL autologous blood. Vital signs, temperatures, cerebral blood flow (CBF), and brain histology were assessed. Brain cooling was performed on the treatment group using the NP-PFC method starting from 20 minutes after SAH. RESULTS No SAH-related deaths were observed in either group. SAH caused an immediate decrease in mean arterial pressure (17.0% ± 4.90% below baseline values). SAH induction caused a significant and rapid decrease in CBF from baseline (approximately -65%, ranging from -32% to -85%) in both hemispheres. In the left hemisphere, cooling facilitated the return of CBF to baseline values within 20 minutes of treatment with further increase in CBF that stabilized by the 2 hours after injury time point. Quantitative immunohistochemistry showed that there were significantly more NeuN-positive cells in the cortex and significantly fewer IBA-1-positive microglia and glial fibrillary acidic protein-positive astrocytes cells in both cortex and hippocampus in the animals that received NP-PFC cooling compared with no treatment, reflecting preserved neuronal integrity and reduced inflammation. CONCLUSIONS The data from this study indicate that local hypothermia by NP-PFC cooling supports return of CBF and neuronal integrity and suppresses the inflammatory response in SAH, suggestive of a promising neuroprotective approach in management of SAH.
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Eroğlu O, Deniz T, Kisa Ü, Atasoy P, Aydinuraz K. Effect of hypothermia on apoptosis in traumatic brain injury and hemorrhagic shock model. Injury 2017; 48:2675-2682. [PMID: 29061477 DOI: 10.1016/j.injury.2017.09.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 09/28/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The neuroprotective mechanisms of therapeutic hypothermia against trauma-related injury have not been fully understood yet. In this study, we aimed to investigate the effects of therapeutic hypothermia on biochemical and histopathological markers of apoptosis using Traumatic brain injury (TBI) and hemorrhagic shock (HS) model. METHODS A total of 50 male albino-wistar rats were divided into five groups: Group isolated TBI, Group NT (HT+HS+normothermia), Group MH (HT+HS+mild hypothermia), Group MoH (HT+HS+moderate hypothermia) and Group C (control). Neurological deficit scores were assessed at baseline and at 24h. The rats were, then, sacrificed to collect serum and brain tissue samples. Levels of Caspase-3,6,8, proteoglycan-4 (PG-4), malondialdehyde (MDA), and nitric oxide (NO) were measured in serum and brain tissue samples. Histopathological examination was performed in brain tissue. RESULTS There were significant differences in the serum levels of Caspase-3 between Group NT and Group C (p=0.018). The serum levels of Caspase-6 in Group NT (0.70±0.58) were lower than Group MH (1.39±0.28), although the difference was not statistically significant (p=0.068). There were significant differences in the brain tissue samples for Caspase-3 levels between Group NT and Group C (p=0.049). A significant difference in the Caspase-8 brain tissue levels was also observed between Group NT and Group C (p=0.022). Group NT had significantly higher scores of all the pathological variables (for edema p<0.017; for gliosis p<0.001; for congestion p<0.003, for hemorrhage p<0.011) than Group C. CONCLUSION Our study results suggest that hypothermia may exert its neuroprotective effects by reducing markers of apoptotic pathway, particularly Caspase-3 on TBI and HS.
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Affiliation(s)
- Oğuz Eroğlu
- Kırıkkale University, Faculty of Medicine, Department of Emergency Medicine, Kırıkkale, Turkey.
| | - Turgut Deniz
- Kırıkkale University, Faculty of Medicine, Department of Emergency Medicine, Kırıkkale, Turkey.
| | - Üçler Kisa
- Kırıkkale University, Faculty of Medicine, Medical Biochemistry, Kırıkkale, Turkey.
| | - Pınar Atasoy
- Kırıkkale University, Faculty of Medicine, Pathology, Kırıkkale, Turkey.
| | - Kuzey Aydinuraz
- Kırıkkale University, Faculty of Medicine, Department of General Surgery, Kırıkkale, Turkey.
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Stocchetti N, Carbonara M, Citerio G, Ercole A, Skrifvars MB, Smielewski P, Zoerle T, Menon DK. Severe traumatic brain injury: targeted management in the intensive care unit. Lancet Neurol 2017; 16:452-464. [PMID: 28504109 DOI: 10.1016/s1474-4422(17)30118-7] [Citation(s) in RCA: 230] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/20/2017] [Accepted: 03/27/2017] [Indexed: 12/11/2022]
Abstract
Severe traumatic brain injury (TBI) is currently managed in the intensive care unit with a combined medical-surgical approach. Treatment aims to prevent additional brain damage and to optimise conditions for brain recovery. TBI is typically considered and treated as one pathological entity, although in fact it is a syndrome comprising a range of lesions that can require different therapies and physiological goals. Owing to advances in monitoring and imaging, there is now the potential to identify specific mechanisms of brain damage and to better target treatment to individuals or subsets of patients. Targeted treatment is especially relevant for elderly people-who now represent an increasing proportion of patients with TBI-as preinjury comorbidities and their therapies demand tailored management strategies. Progress in monitoring and in understanding pathophysiological mechanisms of TBI could change current management in the intensive care unit, enabling targeted interventions that could ultimately improve outcomes.
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Affiliation(s)
- Nino Stocchetti
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy; University of Milan, Department of Pathophysiology and Transplants, Milan, Italy.
| | - Marco Carbonara
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Giuseppe Citerio
- University of Milan-Bicocca, School of Medicine and Surgery, Milan, Italy; San Gerardo Hospital, Neurointensive Care, ASST, Monza, Italy
| | - Ari Ercole
- Addenbrooke's Hospital, Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Markus B Skrifvars
- Monash University, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Melbourne, VIC, Australia; University of Helsinki and Helsinki University Hospital, Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki, Finland
| | - Peter Smielewski
- University of Cambridge Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge, UK
| | - Tommaso Zoerle
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - David K Menon
- Addenbrooke's Hospital, Division of Anaesthesia, University of Cambridge, Cambridge, UK
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Muengtaweepongsa S, Srivilaithon W. Targeted temperature management in neurological intensive care unit. World J Methodol 2017; 7:55-67. [PMID: 28706860 PMCID: PMC5489424 DOI: 10.5662/wjm.v7.i2.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/12/2017] [Accepted: 05/18/2017] [Indexed: 02/06/2023] Open
Abstract
Targeted temperature management (TTM) shows the most promising neuroprotective therapy against hypoxic/ischemic encephalopathy (HIE). In addition, TTM is also useful for treatment of elevated intracranial pressure (ICP). HIE and elevated ICP are common catastrophic conditions in patients admitted in Neurologic intensive care unit (ICU). The most common cause of HIE is cardiac arrest. Randomized control trials demonstrate clinical benefits of TTM in patients with post-cardiac arrest. Although clinical benefit of ICP control by TTM in some specific critical condition, for an example in traumatic brain injury, is still controversial, efficacy of ICP control by TTM is confirmed by both in vivo and in vitro studies. Several methods of TTM have been reported in the literature. TTM can apply to various clinical conditions associated with hypoxic/ischemic brain injury and elevated ICP in Neurologic ICU.
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Brodeur A, Wright A, Cortes Y. Hypothermia and targeted temperature management in cats and dogs. J Vet Emerg Crit Care (San Antonio) 2017; 27:151-163. [PMID: 28122159 DOI: 10.1111/vec.12572] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 03/11/2015] [Accepted: 05/04/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To review current knowledge surrounding the effects, treatment, and prognosis of hypothermia in people, dogs, and cats, as well as the application of therapeutic hypothermia in clinical medicine. ETIOLOGY Hypothermia may be a primary or secondary condition, and may be due to environmental exposure, illness, medications, anesthesia, or trauma. Hypothermia has been applied therapeutically in human medicine for a variety of conditions, including postcardiac arrest. In veterinary medicine, the technique has been applied in cardiac surgeries requiring bypass and in a patient with intractable seizures. DIAGNOSIS Hypothermia can be diagnosed based on presenting temperature or clinical signs, and appropriate diagnosis may require nontraditional thermometers. THERAPY Rewarming is the primary treatment for accidental hypothermia, with intensity ranging from passive surface rewarming to extracorporeal rewarming. The goal is to return the core temperature to a level that restores normal physiologic function of all body processes. Other supportive therapies such as intravenous fluids are typically indicated, and if cardiopulmonary arrest is present, prolonged resuscitation may be required. In cases of secondary hypothermia, reversal of the underlying cause is important. PROGNOSIS There are few prognostic indicators in human and veterinary patients with hypothermia. Even the most severely affected individuals, including those presenting in cardiopulmonary arrest, have potential for complete recovery with appropriate therapy. Therapeutic hypothermia has been shown to improve outcome in people following cardiac arrest. Further studies are needed to examine this application in veterinary medicine, as well as appropriate therapy and prognosis for cases of spontaneous hypothermia.
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Affiliation(s)
| | - Annie Wright
- Maine Veterinary Referral Center, Scarborough, ME, 04074
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Saigal S, Sharma JP, Dhurwe R, Kumar S, Gurjar M. Targeted temperature management: Current evidence and practices in critical care. Indian J Crit Care Med 2015; 19:537-46. [PMID: 26430341 PMCID: PMC4578199 DOI: 10.4103/0972-5229.164806] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Targeted temperature management (TTM) in today's modern era, especially in intensive care units represents a promising multifaceted therapy for a variety of conditions. Though hypothermia is being used since Hippocratic era, the renewed interest of late has been since early 21st century. There have been multiple advancements in this field and varieties of cooling devices are available at present. TTM requires careful titration of its depth, duration and rewarming as it is associated with side-effects. The purpose of this review is to find out the best evidence-based clinical practice criteria of therapeutic hypothermia in critical care settings. TTM is an unique therapeutic modality for salvaging neurological tissue viability in critically ill patients viz. Post-cardiac arrest, traumatic brain injury (TBI), meningitis, acute liver failure and stroke. TTM is standard of care in post-cardiac arrest situations; there has been a lot of controversy of late regarding temperature ranges to be used for the same. In patients with TBI, it reduces intracranial pressure, but has not shown any favorable neurologic outcome. Hypothermia is generally accepted treatment for hypoxic ischemic encephalopathy in newborns. The current available technology to induce and maintain hypothermia allows for precise temperature control. Future studies should focus on optimizing hypothermic treatment to full benefit of our patients and its application in other clinical scenarios.
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Affiliation(s)
- Saurabh Saigal
- Department of Trauma and Emergency Medicine, AIIMS, Bhopal, India
| | | | | | | | - Mohan Gurjar
- Department of Critical Care Medicine, SGPGIMS, Lucknow, India
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Hunter BR, Ellender TJ. Targeted temperature management in emergency medicine: current perspectives. Open Access Emerg Med 2015; 7:69-77. [PMID: 27147892 PMCID: PMC4806809 DOI: 10.2147/oaem.s71279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Landmark trials in 2002 showed that therapeutic hypothermia (TH) after out-of-hospital cardiac arrest due to ventricular tachycardia or ventricular fibrillation resulted in improved likelihood of good neurologic recovery compared to standard care without TH. Since that time, TH has been frequently instituted in a wide range of cardiac arrest patients regardless of initial heart rhythm. Recent evidence has evaluated how, when, and to what degree TH should be instituted in cardiac arrest victims. We outline early evidence, as well as recent trials, regarding the use of TH or targeted temperature management in these patients. We also provide evidence-based suggestions for the institution of targeted temperature management/TH in a variety of emergency medicine settings.
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Affiliation(s)
- Benton R Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Timothy J Ellender
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA; Department of Critical Care Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
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Abend NS, Mani R, Tschuda TN, Chang T, Topjian AA, Donnelly M, LaFalce D, Krauss MC, Schmitt SE, Levine JM. EEG Monitoring during Therapeutic Hypothermia in Neonates, Children, and Adults. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/1086508x.2011.11079816] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Nicholas S. Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ram Mani
- Penn Epilepsy Center, Department of Neurology Hospital of the University of Pennsylvania University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Tammy N. Tschuda
- Departments of Neurology, Children's National Medical Center, Washington, DC
| | - Tae Chang
- Departments of Neurology, Children's National Medical Center, Washington, DC
| | - Alexis A. Topjian
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Maureen Donnelly
- Neurodiagnostic Laboratory, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Denise LaFalce
- Neurodiagnostic Laboratory, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Margaret C. Krauss
- Neurodiagnostic Laboratory, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sarah E. Schmitt
- Penn Epilepsy Center, Department of Neurology Hospital of the University of Pennsylvania University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Joshua M. Levine
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care, Hospital of the University of Pennsylvania University of Pennsylvania School of Medicine Philadelphia, Pennsylvania
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19
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Castillo L, Bugedo G, Rovegno M. Therapeutic hypothermia as a bridge to transplantation in patients with fulminant hepatic failure. Rev Bras Ter Intensiva 2015; 27:72-6. [PMID: 25909316 PMCID: PMC4396900 DOI: 10.5935/0103-507x.20150012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 01/06/2015] [Indexed: 11/20/2022] Open
Abstract
The most important topics in fulminant hepatic failure are cerebral edema and intracranial hypertension. Among all therapeutic options, systemic induced hypothermia to 33 - 34ºC has been reported to reduce the high pressure and increase the time during which patients can tolerate a graft. This review discusses the indications and adverse effects of hypothermia.
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Affiliation(s)
- Luis Castillo
- Departamento de Medicina Intensiva, Pontificia Universidad
Católica de Chile - Santiago, Chile
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Pontificia Universidad
Católica de Chile - Santiago, Chile
| | - Max Rovegno
- Departamento de Medicina Intensiva, Pontificia Universidad
Católica de Chile - Santiago, Chile
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20
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Kulstad EB, Courtney DM, Waller D. Induction of therapeutic hypothermia via the esophagus: a proof of concept study. World J Emerg Med 2014; 3:118-22. [PMID: 25215049 DOI: 10.5847/wjem.j.issn.1920-8642.2012.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 04/12/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Induction of hypothermia (a 4 °C decrease from baseline) improves outcomes in adult cardiac arrest and neonatal hypoxic ischemic encephalopathy, and may benefit other conditions as well. Methods used to implement or prevent hypothermia typically require skin contact with blankets or pads or intravascular access with catheter devices. The study was to evaluate the potential to induce mild therapeutic hypothermia via an esophageal route in a porcine model. METHODS Single-animal proof-of-concept study of a prototype esophageal device in a 70 kg Yorkshire swine. We measured the rate of temperature change after placement of a prototype device to induce hypothermia via the esophagus, and compared this rate to known temperature changes that occur under similar laboratory conditions without a hypothermic device. RESULTS Swine temperature decreased from a starting temperature of 37.8 °C to 33.8 °C (achieving the goal of a 4 °C decrease) in 175 minutes, resulting in a cooling rate of 1.37 °C/h. Histopathology of the esophagus showed normal tissue without evidence of injury. CONCLUSION A prototype of an esophageal cooling device induced hypothermia effectively in a large single-swine model.
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Affiliation(s)
- Erik B Kulstad
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - D Mark Courtney
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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21
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Hessel EA. Therapeutic hypothermia after in-hospital cardiac arrest: a critique. J Cardiothorac Vasc Anesth 2014; 28:789-99. [PMID: 24751488 DOI: 10.1053/j.jvca.2014.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Indexed: 02/08/2023]
Abstract
More than 210,000 in-hospital cardiac arrests occur annually in the United States. Use of moderate therapeutic hypothermia (TH) in comatose survivors after return of spontaneous circulation following out-of-hospital cardiac arrest (OOH-CA) caused by ventricular fibrillation or pulseless ventricular tachycardia is recommended strongly by many professional organizations and societies. The use of TH after cardiac arrest associated with nonshockable rhythms and after in-hospital cardiac arrest (IH-CA) is recommended to be considered by these same organizations and is being applied widely. The use in these latter circumstances is based on an extrapolation of the data supporting its use after out-of-hospital cardiac arrest associated with shockable rhythms. The purpose of this article is to review the limitations of existing data supporting these extended application of TH after cardiac arrest and to suggest approaches to this dilemma. The data supporting its use for OOH-CA appear to this author, and to some others, to be rather weak, and the data supporting the use of TH for IH-CA appear to be even weaker and to include no randomized controlled trials (RCTs) or supportive observational studies. The many reasons why TH might be expected to be less effective following IH-CA are reviewed. The degree of neurologic injury may be more severe in many of these cases and, thus, may not be responsive to TH as currently practiced following OOH-CA. The potential adverse consequences of the routine use of TH for IH-CA are listed and include complications associated with TH, interference with diagnostic and interventional therapy, and use of scarce personnel and financial resources. Most importantly, it inhibits the ability of researchers to conduct needed RCTs. The author believes that the proper method of providing TH in these cases needs to be better defined. Based on this analysis the author concludes that TH should not be used indiscriminantly following most cases of IH-CA, and instead clinicians should concentrate their efforts in conducting high-quality large RCTs or large-scale, well-designed prospective observation studies to determine its benefits and identify appropriate candidates.
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Affiliation(s)
- Eugene A Hessel
- Department of Anesthesiology, Surgery (Cardiothoracic), Neurosurgery, and Pediatrics, University of Kentucky College of Medicine, Lexington, KY.
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22
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Kulstad E, Metzger AK, Courtney DM, Rees J, Shanley P, Matsuura T, McKnite S, Lurie K. Induction, maintenance, and reversal of therapeutic hypothermia with an esophageal heat transfer device. Resuscitation 2013; 84:1619-24. [DOI: 10.1016/j.resuscitation.2013.06.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 05/22/2013] [Accepted: 06/20/2013] [Indexed: 10/26/2022]
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Hernández-Guillamon M, Ortega L, Merino-Zamorano C, Campos-Martorell M, Rosell A, Montaner J. Mild hypothermia protects against oxygen glucose deprivation (OGD)-induced cell death in brain slices from adult mice. J Neural Transm (Vienna) 2013; 121:113-7. [DOI: 10.1007/s00702-013-1090-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 09/02/2013] [Indexed: 11/30/2022]
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Ballesteros MA, Marín MJ, Martín MS, Rubio-Lopez MI, López-Hoyos M, Miñambres E. Effect of neuroprotective therapies (hypothermia and cyclosporine a) on dopamine-induced apoptosis in human neuronal SH-SY5Y cells. Brain Inj 2013; 27:354-60. [PMID: 23438355 DOI: 10.3109/02699052.2012.743184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION This study aimed to evaluate the effect of hypothermia and CyA on neuronal survival after induced injury in a neuronal model. METHODS Human neuroblastoma SH-SY5Y cells were seeded and allowed to grow. To determine whether lower temperatures protect from dopamine-induced apoptosis, cells were treated with dopamine at 100 µM, at 300 µM or without dopamine and incubated at 32 °C or 37 °C for 24 hours. To assess the effect of CyA, cells were pre-incubated with CyA at 37 °C and after dopamine was added. RESULTS After 24 hours of incubation at 37 °C, 100 µM and 300 µM dopamine induced 42% (SD = 21) and 58% (SD = 7.9) apoptotic SH-SY5 cells, respectively. In cultures at 32 °C dopamine-induced apoptosis could be reversed by hypothermia [7% (SD = 1.4) and 3.45% (SD = 1.1) for 100 µM and 300 µM, respectively], similar to levels obtained in non-treated cells [2.4% (SD = 1.5)]. Cyclosporine A treatment did not render the expected result, since CyA-pre-treated cells and SH-SY5Y cells showed higher levels of apoptosis than those observed with dopamine alone CONCLUSIONS Hypothermia has a marked protective effect against apoptotic cell death induced by dopamine in a human neuroblastic cell line. The neuroprotective effect of CyA described with other apoptotic cell death stimuli was not demonstrated with our experimental conditions.
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Affiliation(s)
- María A Ballesteros
- Department of Critical Care Medicine, University Hospital Marqués de Valdecilla-IFIMAV, Santander, Spain.
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Gibson A, Andrews PJD. Therapeutic hypothermia, still "too cool to be true?". F1000PRIME REPORTS 2013; 5:26. [PMID: 23878730 PMCID: PMC3702220 DOI: 10.12703/p5-26] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Therapeutic hypothermia, an intervention reducing core body temperature below 35 degrees Celsius, has gained popularity in the management of acute brain injury after a series of small clinical trials in patients following cardiac arrest, stroke and traumatic brain injury. This article reviews the evidence relating to therapeutic hypothermia as an intervention in acute injury.
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Affiliation(s)
- Alistair Gibson
- Department of Anaesthesia & Critical Care, University of Edinburgh & NHS LothianWestern General Hospital, EdinburghUnited Kingdom, EH12 6ER
| | - Peter J. D. Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh & NHS LothianWestern General Hospital, EdinburghUnited Kingdom, EH12 6ER
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Sakurai A, Atkins CM, Alonso OF, Bramlett HM, Dietrich WD. Mild hyperthermia worsens the neuropathological damage associated with mild traumatic brain injury in rats. J Neurotrauma 2012; 29:313-21. [PMID: 22026555 DOI: 10.1089/neu.2011.2152] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The effects of slight variations in brain temperature on the pathophysiological consequences of acute brain injury have been extensively described in models of moderate and severe traumatic brain injury (TBI). In contrast, limited information is available regarding the potential consequences of temperature elevations on outcome following mild TBI (mTBI) or concussions. One potential confounding variable with mTBI is the presence of elevated body temperature that occurs in the civilian or military populations due to hot environments combined with exercise or other forms of physical exertion. We therefore determined the histopathological effects of pre- and post-traumatic hyperthermia (39°C) on mTBI. Adult male Sprague-Dawley rats were divided into 3 groups: pre/post-traumatic hyperthermia, post-traumatic hyperthermia alone for 2 h, and normothermia (37°C). The pre/post-hyperthermia group was treated with hyperthermia starting 15 min before mild parasagittal fluid-percussion brain injury (1.4-1.6 atm), with the temperature elevation extending for 2 h after trauma. At 72 h after mTBI, the rats were perfusion-fixed for quantitative histopathological evaluation. Contusion areas and volumes were significantly larger in the pre/post-hyperthermia treatment group compared to the post-hyperthermia and normothermic groups. In addition, pre/post-traumatic hyperthermia caused the most severe loss of NeuN-positive cells in the dentate hilus compared to normothermia. These neuropathological results demonstrate that relatively mild elevations in temperature associated with peri-traumatic events may affect the long-term functional consequences of mTBI. Because individuals exhibiting mildly elevated core temperatures may be predisposed to aggravated brain damage after mTBI or concussion, precautions should be introduced to target this important physiological variable.
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Affiliation(s)
- Atsushi Sakurai
- The Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida, USA
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Rosenfeld JV, Maas AI, Bragge P, Morganti-Kossmann MC, Manley GT, Gruen RL. Early management of severe traumatic brain injury. Lancet 2012; 380:1088-98. [PMID: 22998718 DOI: 10.1016/s0140-6736(12)60864-2] [Citation(s) in RCA: 352] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Severe traumatic brain injury remains a major health-care problem worldwide. Although major progress has been made in understanding of the pathophysiology of this injury, this has not yet led to substantial improvements in outcome. In this report, we address present knowledge and its limitations, research innovations, and clinical implications. Improved outcomes for patients with severe traumatic brain injury could result from progress in pharmacological and other treatments, neural repair and regeneration, optimisation of surgical indications and techniques, and combination and individually targeted treatments. Expanded classification of traumatic brain injury and innovations in research design will underpin these advances. We are optimistic that further gains in outcome for patients with severe traumatic brain injury will be achieved in the next decade.
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Affiliation(s)
- Jeffrey V Rosenfeld
- Department of Neurosurgery, The Alfred Hospital, Monash University, Melbourne, Australia.
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Controversies in the management of adults with severe traumatic brain injury. AACN Adv Crit Care 2012; 23:188-203. [PMID: 22543492 DOI: 10.1097/nci.0b013e31824db4f3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite progress in the management of adults with severe traumatic brain injury, several controversies persist. Among the unresolved issues of greatest concern to neurocritical care clinicians and scientists are the following: (1) the best use of technological advances and the data obtained from multimodality monitoring; (2) the use of mannitol and hypertonic saline in the management of increased intracranial pressure; (3) the use of decompressive craniectomy and barbiturate coma in refractory increased intracranial pressure; (4) therapeutic hypothermia as a neuroprotectant; (5) anemia and the role of blood transfusion; and (6) venous thromboembolism prophylaxis in severe traumatic brain injury. Each of these strategies for managing severe traumatic brain injury, including the postulated mechanism(s) of action and beneficial effects of each intervention, adverse effects, the state of the science, and critical care nursing implications, is discussed.
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Koehn J, Kollmar R, Cimpianu CL, Kallmünzer B, Moeller S, Schwab S, Hilz MJ. Head and neck cooling decreases tympanic and skin temperature, but significantly increases blood pressure. Stroke 2012; 43:2142-8. [PMID: 22627986 DOI: 10.1161/strokeaha.112.652248] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Localized head and neck cooling might be suited to induce therapeutic hypothermia in acute brain injury such as stroke. Safety issues of head and neck cooling are undetermined and may include cardiovascular autonomic side effects that were identified in this study. METHODS Ten healthy men (age 35±13 years) underwent 120 minutes of combined head and neck cooling (Sovika, HVM Medical). Before and after onset of cooling, after 60 and 120 minutes, we determined rectal, tympanic, and forehead skin temperatures, RR intervals, systolic and diastolic blood pressures (BP), laser-Doppler skin blood flow at the index finger and cheek, and spectral powers of mainly sympathetic low-frequency (0.04-0.15 Hz) and parasympathetic high-frequency (0.15-0.5 Hz) RR interval oscillations and sympathetic low-frequency oscillations of BP. We compared values before and during cooling using analysis of variance with post hoc analysis; (significance, P<0.05). RESULTS Forehead skin temperature dropped by 5.5±2.2°C with cooling onset and by 12.4±3.2°C after 20 minutes. Tympanic temperature decreased by 4.7±0.7°C within 40 minutes, and rectal temperature by only 0.3±0.3°C after 120 minutes. Systolic and diastolic BP increased immediately on cooling onset and rose by 15.3±20.8 mm Hg and 16.5±13.4 mm Hg (P=0.004) after 120 minutes, whereas skin blood flow fell significantly during cooling. RR intervals and parasympathetic RR interval high-frequency powers increased with cooling onset and were significantly higher after 60 and 120 minutes than they were before cooling. CONCLUSIONS Head and neck cooling prominently reduced tympanic temperature and thus might also induce intracerebral hypothermia; however, it did not significantly lower body core temperature. Profound skin temperature decrease induced sympathetically mediated peripheral vasoconstriction and prominent BP increases that are not offset by simultaneous parasympathetic heart rate slowing. Prominent peripheral vasoconstriction and BP increase must be considered as possibly harmful during head and neck cooling.
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Affiliation(s)
- Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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Menuet C, Borghgraef P, Voituron N, Gestreau C, Gielis L, Devijver H, Dutschmann M, Van Leuven F, Hilaire G. Isoflurane anesthesia precipitates tauopathy and upper airways dysfunction in pre-symptomatic Tau.P301L mice: Possible implication for neurodegenerative diseases. Neurobiol Dis 2012; 46:234-43. [DOI: 10.1016/j.nbd.2012.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 12/14/2011] [Accepted: 01/23/2012] [Indexed: 11/26/2022] Open
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Abstract
OPINION STATEMENT: The use of tissue plasminogen activator (tPA) is the major treatment method for acute ischemic stroke, but it reaches only a very limited number of stroke patients. Although neuroprotectants may be useful in stroke patients in principle, promising animal data have not yet been successfully transferred to stroke patients. However, many arguments favor the successful translation of therapeutic hypothermia (TH) to stroke patients: it is a multimodal method, there is a strong correlation between fever and outcome in stroke patients, and TH has been shown to be beneficial in other kinds of acute brain injury (resuscitation, perinatal asphyxia). In addition, it is useful in controlling intracranial pressure caused by brain edema. So far, available data from clinical studies are not sufficient to recommend TH for the routine treatment of acute ischemic stroke. The quality of trials and the number of stroke patients treated by TH are far too low to prove efficacy or futility, but multicenter randomized controlled clinical trials are on their way. Studies in awake stroke patients will use TH very early in the clinical setting, which implies certain problems. The use of TH in awake individuals requires methods to suppress cold-induced vegetative responses such as shivering and sympathic activation, clinically relevant side effects that need to be monitored and treated carefully. In mass-occupying ischemic stroke, randomized trials will evaluate the neuroprotective effects of controlling edema and intracranial pressure. Because the optimal depth, duration, and methods of cooling are not clear, only large randomized controlled trials will set the baseline from which TH as a neuroprotective therapy can be optimized and brought successfully to stroke patients.
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Affiliation(s)
- Rainer Kollmar
- Department of Neurology, University of Erlangen-Nuernberg, Schwabachanlage 6, 91054, Erlangen, Germany,
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Cold-inducible RNA binding protein inhibits H₂O₂-induced apoptosis in rat cortical neurons. Brain Res 2012; 1441:47-52. [PMID: 22297174 DOI: 10.1016/j.brainres.2011.12.053] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 12/09/2011] [Accepted: 12/27/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The expression cold-inducible RNA-binding protein (CIRP) is significantly enhanced in neurons under hypothermia, but its roles remain unclear. This study aims to investigate whether the cerebral protection under hypothermia is mediated by the CIRP-mediated inhibition of neuronal apoptosis. METHODS Primary rat cortical neurons were isolated, cultured, and transduced with lentiviral CIRP-RNAi. Apoptosis of the transduced neurons was induced with 100 μmol/L H₂O₂, the treated cells were divided into two groups, and cultured in 37 °C or 32 °C incubator respectively. Cell viability was detected by MTT colorimetric assay. Neuronal apoptosis was detected by flow cytometry after labeling the cells with Hoechst 33342 and Annexin V-FITC/PI. The protein expressions of CIRP, activated caspase-3, and thioredoxin (TRX) were detected by Western blot. RESULTS Under 32 °C, CIRP protein is significantly induced in cortical neurons; the expression of activated caspase-3 decreases, while the TRX expression increases. The rate of neuronal apoptosis is 4.5±0.8%. Under 37 °C, CIRP expression is evidently reduced in cortical neurons; the expression of activated caspase-3 is significantly enhanced with reduced level of TRX expression. The rate of neuronal apoptosis reaches 53.5±1.7% (P < 0.05, compared to that in 32 °C group). CONCLUSIONS The induction of CIRP protein in rat cortical neurons under hypothermia inhibits H₂O₂-induced neuronal apoptosis and thereby exerts neuroprotective effect, which forms one of the cerebral protective pathways under hypothermia.
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Therapeutic Targeting of Astrocytes After Traumatic Brain Injury. Transl Stroke Res 2011; 2:633-42. [DOI: 10.1007/s12975-011-0129-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 10/21/2011] [Accepted: 10/25/2011] [Indexed: 10/15/2022]
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Abstract
Head injury is one of the major causes of trauma-related morbidity and mortality in all age groups in the United Kingdom, and anaesthetists encounter this problem in many areas of their work. Despite a better understanding of the pathophysiological processes following traumatic brain injury and a wealth of research, there is currently no specific treatment. Outcome remains dependant on basic clinical care: management of the patient's airway with particular attention to preventing hypoxia; avoidance of the extremes of lung ventilation; and the maintenance of adequate cerebral perfusion, in an attempt to avoid exacerbating any secondary injury. Hypertonic fluids show promise in the management of patients with raised intracranial pressure. Computed tomography scanning has had a major impact on the early identification of lesions amenable to surgery, and recent guidelines have rationalised its use in those with less severe injuries. Within critical care, the importance of controlling blood glucose is becoming clearer, along with the potential beneficial effects of hyperoxia. The major improvement in outcome reflects the use of protocols to guide resuscitation, investigation and treatment and the role of specialist neurosciences centres in caring for these patients. Finally, certain groups are now recognised as being at greater risk, in particular the elderly, anticoagulated patient.
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Abend NS, Mani R, Tschuda TN, Chang T, Topjian AA, Donnelly M, LaFalce D, Krauss MC, Schmitt SE, Levine JM. EEG monitoring during therapeutic hypothermia in neonates, children, and adults. AMERICAN JOURNAL OF ELECTRONEURODIAGNOSTIC TECHNOLOGY 2011; 51:141-164. [PMID: 21988034 PMCID: PMC3422126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Therapeutic hypothermia is being utilized as a neuroprotective strategy in neonates, children, and adults. The most common indications are hypoxic ischemic encephalopathy in neonates and post cardiac arrest in adults. Electroencephalographic monitoring use is increasing in critical care units, and is sometimes a component of therapeutic hypothermia clinical pathways. Monitoring may detect non-convulsive seizures or non-convulsive status epilepticus, and it may provide prognostic information. We review data regarding indications for therapeutic hypothermia and electroencephalographic monitoring in neonatal, pediatric, and adult critical care units, and discuss technical aspects related to such monitoring.
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Affiliation(s)
- Nicholas S Abend
- Department of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Abstract
Traumatic brain injury is the leading cause of death in young people. Induced hypothermia has been used as a therapeutic intervention to improve outcome, based on results of animal studies. This article reviews the mechanisms of brain injury, the results of animal and human studies and the reasons that human studies do not always reflect the success seen in animal studies and why results may be ‘lost in translation’ to treatment of patients. It concludes by suggesting further areas of work to investigate the clinical use of therapeutic hypothermia.
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Affiliation(s)
- Liming Qiu
- Medical Student, Bart's and the London Medical School
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Kovács E, Jenei Z, Horváth A, Gellér L, Szilágyi S, Király A, Molnár L, Sótonyi P, Merkely B, Zima E. [Physiologic effects of hypothermia]. Orv Hetil 2011; 152:171-81. [PMID: 21247858 DOI: 10.1556/oh.2011.29006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Therapeutic use of hypothermia has come to the frontline in the past decade again in the prevention and in mitigation of neurologic impairment. The application of hypothermia is considered as a successful therapeutic measure not just in neuro- or cardiac surgery, but also in states causing brain injury or damage. According to our present knowledge this is the only proven therapeutic tool, which improves the neurologic outcome after cardiac arrest, decreasing the oxygen demand of the brain. Besides influencing the nervous system, hypothermia influences the function of the whole organ system. Beside its beneficial effects, it has many side-effects, which may be harmful to the patient. Before using it for a therapeutic purpose, it is very important to be familiar with the physiology and complications of hypothermia, to know, how to prevent and treat its side-effects. The purpose of this article is to summarize the physiologic and pathophysiologic effects of hypothermia.
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Affiliation(s)
- Eniko Kovács
- Semmelweis Egyetem, Általános Orvostudományi Kar Kardiológiai Központ, Kardiológiai Tanszék Budapest Városmajor u. 68. 1122
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Andrews PJD, Citerio G. EUROTHERM3235Trial. Intensive Care Med 2010; 36:1990-2. [PMID: 20859614 DOI: 10.1007/s00134-010-2031-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 07/23/2010] [Indexed: 11/25/2022]
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