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Birbeck GL, Seydel KB, Mwanza S, Tembo D, Chilombe M, Watts A, Ume-Ezeoke I, Mathews M, Patel AA, Mwenechanya M, Pensulo P, McDermott MP. Acetaminophen and Ibuprofen in Pediatric Central Nervous System Malaria: A Randomized Clinical Trial. JAMA Neurol 2024:2819810. [PMID: 38857015 PMCID: PMC11165415 DOI: 10.1001/jamaneurol.2024.1677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/21/2024] [Indexed: 06/11/2024]
Abstract
Importance A third of children who survive malaria with neurological involvement (central nervous system [CNS] malaria) develop sequelae. A higher maximum temperature (Tmax) and seizures are risk factors for sequelae. Objective To compare aggressive antipyretic therapy using scheduled acetaminophen and ibuprofen vs usual care with acetaminophen alone given only for a temperature of 38.5 °C or higher. Design, Setting, and Participants This randomized clinical trial was conducted at inpatient pediatric services of 1 tertiary care and 1 district hospital in Zambia and a tertiary care center in Malawi. Included were children aged 2 to 11 years with CNS malaria (excluding those with creatinine >1.2 mg/dL), who were enrolled from 2019 to 2022. Data analysis took place from December 2022 to April 2023. Intervention The aggressive antipyretic group received acetaminophen (30 mg/kg load, then 15 mg/kg) plus ibuprofen, 10 mg/kg, every 6 hours, regardless of clinical temperature for 72 hours. The usual care group received 15 mg/kg of acetaminophen as needed every 6 hours for a temperature of 38.5 °C or higher. Main Outcomes and Measures The primary outcome variable was Tmax over 72 hours, the total duration of follow-up. Secondary outcomes included seizures and parasite clearance. Results Five hundred fifty-three patients were screened, 226 (40.9%) were ineligible, and 57 (10.3%) declined. A total 256 participants (n = 128/group) had a mean (SD) age of 4.3 (2.1) years; 115 (45%) were female, and 141 (55%) were male. The aggressive antipyretic group had a lower Tmax, 38.6 vs 39.2 °C (difference, -0.62 °C; 95% CI, -0.82 to -0.42; P < .001) and lower odds of experiencing multiple or prolonged seizures, 10 (8%) vs 34 children (27%) in the usual care group (odds ratio [OR], 0.26; 95% CI, 0.12 to 0.56). No group difference in parasite clearance time was detected. Severe adverse events occurred in 40 children (15%), 25 (20%) in the usual care group and 15 (12%) in the aggressive antipyretic group, including 13 deaths (10 [8%] and 3 [2%], respectively). Increased creatinine resulted in study drug discontinuation in 8 children (6%) in the usual care group and 13 children (10%) in the aggressive antipyretic group (OR, 1.74; 95% CI, 0.63 to 5.07). Conclusions and Relevance This study found that aggressive antipyretic therapy reduced mean Tmax to temperature levels comparable with the Tmax among children without neurological impairments in prior observational studies and improved acute seizure outcomes with no prolongation of parasitemia. Trial Registration ClinicalTrials.gov Identifier: NCT03399318.
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Affiliation(s)
- Gretchen L. Birbeck
- Epilepsy Division, Department of Neurology, University of Rochester, Rochester, New York
- University Teaching Hospitals Neurology Research Office, Lusaka, Zambia
- Department of Paediatrics and Child Health, University Teaching Hospitals Children’s Hospital, Lusaka, Zambia
| | - Karl B. Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing
| | - Suzanna Mwanza
- Department of Paediatrics and Child Health, Chipata Central Hospital, Chipata, Zambia
| | - Derby Tembo
- University Teaching Hospitals Neurology Research Office, Lusaka, Zambia
- Department of Paediatrics and Child Health, Chipata Central Hospital, Chipata, Zambia
- Department of Paediatrics and Child Health, University Teaching Hospitals Children’s Hospital, Lusaka, Zambia
| | - Moses Chilombe
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Arthur Watts
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Ifunanya Ume-Ezeoke
- Epilepsy Division, Department of Neurology, University of Rochester, Rochester, New York
| | - Manoj Mathews
- Department of Paediatrics and Child Health, University Teaching Hospitals Children’s Hospital, Lusaka, Zambia
| | - Archana A. Patel
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Musaku Mwenechanya
- Department of Paediatrics and Child Health, University Teaching Hospitals Children’s Hospital, Lusaka, Zambia
| | - Paul Pensulo
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
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Gard A, Vedung F, Piehl F, Khademi M, Wernersson MP, Rorsman I, Tegner Y, Pessah-Rasmussen H, Ruscher K, Marklund N. Cerebrospinal fluid levels of neuroinflammatory biomarkers are increased in athletes with persistent post-concussive symptoms following sports-related concussion. J Neuroinflammation 2023; 20:189. [PMID: 37592277 PMCID: PMC10433539 DOI: 10.1186/s12974-023-02864-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/29/2023] [Indexed: 08/19/2023] Open
Abstract
A sports-related concussion (SRC) is often caused by rapid head rotation at impact, leading to shearing and stretching of axons in the white matter and initiation of secondary inflammatory processes that may exacerbate the initial injury. We hypothesized that athletes with persistent post-concussive symptoms (PPCS) display signs of ongoing neuroinflammation, as reflected by altered profiles of cerebrospinal fluid (CSF) biomarkers, in turn relating to symptom severity. We recruited athletes with PPCS preventing sports participation as well as limiting work, school and/or social activities for ≥ 6 months for symptom rating using the Sport Concussion Assessment Tool, version 5 (SCAT-5) and for cognitive assessment using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Following a spinal tap, we analysed 27 CSF inflammatory biomarkers (pro-inflammatory chemokines and cytokine panels) by a multiplex immunoassay using antibodies as electrochemiluminescent labels to quantify concentrations in PPCS athletes, and in healthy age- and sex-matched controls exercising ≤ 2 times/week at low-to-moderate intensity. Thirty-six subjects were included, 24 athletes with PPCS and 12 controls. The SRC athletes had sustained a median of five concussions, the most recent at a median of 17 months prior to the investigation. CSF cytokines and chemokines levels were significantly increased in eight (IL-2, TNF-α, IL-15, TNF-β, VEGF, Eotaxin, IP-10, and TARC), significantly decreased in one (Eotaxin-3), and unaltered in 16 in SRC athletes when compared to controls, and two were un-detectable. The SRC athletes reported many and severe post-concussive symptoms on SCAT5, and 10 out of 24 athletes performed in the impaired range (Z < - 1.5) on cognitive testing. Individual biomarker concentrations did not strongly correlate with symptom rating or cognitive function. Limitations include evaluation at a single post-injury time point in relatively small cohorts, and no control group of concussed athletes without persisting symptoms was included. Based on CSF inflammatory marker profiling we find signs of ongoing neuroinflammation persisting months to years after the last SRC in athletes with persistent post-concussive symptoms. Since an ongoing inflammatory response may exacerbate the brain injury these results encourage studies of treatments targeting the post-injury inflammatory response in sports-related concussion.
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Affiliation(s)
- Anna Gard
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
| | - Fredrik Vedung
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Mohsen Khademi
- Department of Clinical Neuroscience, Neuroimmunology Unit, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | | | - Ia Rorsman
- Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Yelverton Tegner
- Department of Health Sciences, Luleå University of Technology, Luleå, Sweden
| | - Hélène Pessah-Rasmussen
- Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
| | - Karsten Ruscher
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skåne University Hospital EA-Blocket Plan 4, Klinikgatan 17A7, 221 85 Lund, Sweden
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3
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Kim H. Anesthetic management of the traumatic brain injury patients undergoing non-neurosurgery. Anesth Pain Med (Seoul) 2023; 18:104-113. [PMID: 37183278 PMCID: PMC10183618 DOI: 10.17085/apm.23017] [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: 02/27/2023] [Accepted: 03/15/2023] [Indexed: 05/16/2023] Open
Abstract
This article describes the anesthetic management of patients with traumatic brain injury (TBI) undergoing non-neurosurgery, primarily targeting intraoperative management for multiple-trauma surgery. The aim of this review is to promote the best clinical practice for patients with TBI in order to prevent secondary brain injury. Based on the current clinical guidelines and evidence, anesthetic selection and administration; maintenance of optimal cerebral perfusion pressure, oxygenation and ventilation; coagulation monitoring; glucose control; and temperature management are addressed. Neurological recovery, which is critical for improving the patient's quality of life, is most important; therefore, future research needs to be focused on this aspect.
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Affiliation(s)
- Hyunjee Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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4
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Cavazzoni E, Boakye T. A 12-Year Audit of Neurological Outcomes Associated with Core Body Temperature >37.5°C in Children with Severe Traumatic Brain Injury. Ther Hypothermia Temp Manag 2022. [PMID: 36355047 DOI: 10.1089/ther.2022.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Hyperthermia exposure is associated with poor neurological outcomes in patients with severe traumatic brain injury (TBI). Our aim was to describe fever in children with severe TBI admitted to a pediatric intensive care unit (PICU) for at least 72 hours and to evaluate associations between fever using a novel approach to describe thermal exposure and neurobehavioral outcomes. The cohort included children from birth to 17 years of age admitted to the PICU between 2000 and 2012 for at least 72 hours who had severe TBI with intracranial pressure monitoring. Patients with non-accidental TBI or pre-existing developmental delays were excluded. Hyperthermia was defined as a core temperature >37.5°C. Hourly temperature measurements were used to calculate the area under the curve (AUC) using the linear trapezoidal rule. Each participant was followed up at the Brain Injury Clinic 6 and 18 months postinjury. Neurobehavioral outcome scores were analyzed against AUC using standard statistical methods. Ninety-eight patients admitted with severe TBI met the study inclusion criteria. Hyperthermia/fever was common (89.7%), and patients remained hyperthermic for a median of 9.4 hours. However, no statistically significant association was found between AUC and abnormal neurological outcomes. The follow-up rates were good at 6 (86.7%) and 18 months (83.7%). The neurological deficit improved with time, with "favorable outcomes" increasing from 72% to 94% at the respective follow-up months. Our study used a novel method to describe patients' fever, providing a different indicator of thermal exposure than that previously reported. In addition, the AUC was well correlated with the maximum temperature recorded and the proportion of time >37.5°C, indicating that it is a good surrogate for thermal exposure. Interestingly, the neurological disabilities of the patients improved over time.
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Affiliation(s)
- Elena Cavazzoni
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Westmead, Australia
| | - Thomas Boakye
- Children's Critical Care Unit, Gold Coast University Hospital, Gold Coast, Australia
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5
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Abstract
PURPOSE OF REVIEW Fever is common after acute brain injury and is associated with poor prognosis in this setting. RECENT FINDINGS Achieving normothermia is feasible in patients with ischemic or hemorrhagic stroke, subarachnoid hemorrhage and traumatic brain injury. Pharmacological strategies (i.e. paracetamol or nonsteroidal anti-inflammatory drugs) are frequently ineffective and physical (i.e. cooling devices) therapies are often required. There are no good quality data supporting any benefit from therapeutic strategies aiming at normothermia in all brain injured patients when compared with standard of care, where mild-to-moderate fever is tolerated. However, recent guidelines recommended fever control in this setting. SUMMARY As fever is considered a clinically relevant secondary brain damage, we have provided an individualized therapeutic approach to treat it in brain injured patients, which deserved further validation in the clinical setting.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Erasmus Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Gard A, Tegner Y, Bakhsheshi MF, Marklund N. Selective head-neck cooling after concussion shortens return-to-play in ice hockey players. Concussion 2021; 6:CNC90. [PMID: 34084556 PMCID: PMC8162197 DOI: 10.2217/cnc-2021-0002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We aimed to investigate whether selective head–neck cooling could shorten recovery after sports-related concussions (SRCs). In a nonrandomized study of 15 Swedish professional ice hockey teams, 29 concussed players received immediate head and neck cooling for ≥30 min (initiated at 12.3 ± 9.2 min post-SRC by a portable cooling system), and 52 SRC controls received standard management. Players receiving head–neck cooling had shorter time to return-to-play than controls (7 vs 12.5 days, p < 0.0001), and 7% in the intervention group versus 25% in the control group were out of play for ≥3 weeks (p = 0.07). Immediate selective head–neck cooling is a promising option in the acute management of SRC that should be addressed in larger cohorts.
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Affiliation(s)
- Anna Gard
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Neurosurgery, Lund, Sweden
| | - Yelverton Tegner
- Department of Health Sciences, Luleå University of Technology, Luleå, Sweden
| | - Mohammad Fazel Bakhsheshi
- Lund University, Family Medicine & Community Medicine, Lund, Sweden.,BrainCool AB, Medicon Village, Lund, Sweden
| | - Niklas Marklund
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Neurosurgery, Lund, Sweden
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7
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Shepley BR, Ainslie PN, Hoiland RL, Donnelly J, Sekhon MS, Zetterberg H, Blennow K, Bain AR. Negligible influence of moderate to severe hyperthermia on blood-brain barrier permeability and neuronal parenchymal integrity in healthy men. J Appl Physiol (1985) 2021; 130:792-800. [PMID: 33444119 DOI: 10.1152/japplphysiol.00645.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
With growing use for hyperthermia as a cardiovascular therapeutic, there is surprisingly little information regarding the acute effects it may have on the integrity of the neurovascular unit (NVU). Indeed, relying on animal data would suggest hyperthermia comparable to levels attained in thermal therapy will disrupt the blood-brain barrier (BBB) and damage the cerebral parenchymal cells. We sought to address the hypothesis that controlled passive hyperthermia is not sufficient to damage the NVU in healthy humans. Young men (n = 11) underwent acute passive heating until +2°C or absolute esophageal temperature of 39.5°C. The presence of BBB opening was determined by trans-cerebral exchange kinetics (radial-arterial and jugular venous cannulation) of S100B. Neuronal parenchymal damage was determined by the trans-cerebral exchange of tau protein, neuron-specific enolase (NSE), and neurofilament-light protein (NF-L). Cerebral blood flow to calculate exchange kinetics was measured by duplex ultrasound of the right internal carotid and left vertebral artery. Passive heating was performed via a warm-water perfused suit. In hyperthermia, there was no increase in the cerebral exchange of S100B (P = 0.327), tau protein (P = 0.626), NF-L (P = 0.447), or NSE (P = 0.908) suggesting the +2°C core temperature is not sufficient to acutely stress the NVU in healthy men. However, there was a significant condition effect (P = 0.028) of NSE, corresponding to a significant increase in arterial (P = 0.023) but not venous (P = 0.173) concentrations in hyperthermia, potentially indicating extra-cerebral release of NSE. Collectively, results from the present study support the notion that in young men there is little concern for NVU damage with acute hyperthermia of +2 °C.NEW & NOTEWORTHY The acute effects of passive whole-body hyperthermia on the integrity of the neurovascular unit (NVU) in humans have remained unclear. We demonstrate that passive heating for ∼1 h until an increase of +2°C esophageal temperature in healthy men does not increase the cerebral release of neuronal parenchymal stress biomarkers, suggesting the NVU integrity is maintained. This preliminary study indicates passive heating is safe for the brain, at least in young healthy men.
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Affiliation(s)
- Brooke R Shepley
- University of Windsor, Faculty of Human Kinetics, Department of Kinesiology, Windsor, ON, Canada
| | - Philip N Ainslie
- University of British Columbia, Kelowna, Centre for Heart Lung and Vascular Health, Vancouver, BC, Canada
| | - Ryan L Hoiland
- University of British Columbia, Kelowna, Centre for Heart Lung and Vascular Health, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology, and Therapeutics, Vancouver General Hospital, Vancouver, BC, Canada
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | - Mypinder S Sekhon
- University of British Columbia, Kelowna, Centre for Heart Lung and Vascular Health, Vancouver, BC, Canada.,Division of Critical Care Medicine and Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Anthony R Bain
- University of Windsor, Faculty of Human Kinetics, Department of Kinesiology, Windsor, ON, Canada
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Pegoli M, Zurlo Z, Bilotta F. Temperature management in acute brain injury: A systematic review of clinical evidence. Clin Neurol Neurosurg 2020; 197:106165. [PMID: 32937217 DOI: 10.1016/j.clineuro.2020.106165] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/09/2020] [Accepted: 08/19/2020] [Indexed: 01/13/2023]
Abstract
Temperature alterations in neurocritical care settings are common and have a striking effect on brain metabolism leading to or exacerbating neuronal injury. Hyperthermia worsens acute brain injury (ABI) patients outcome. However conclusive evidence linking control of temperature to improved outcome is still lacking. This review article report an update -results from clinical studies published between March 2006 and March 2020- on the relationship between hyperthermia or Target Temperature Management and functional outcome or mortality in ABI patients. MATERIALS AND METHODS A systematic search of articles in PubMed and EMBASE database was accomplished. Only complete studies, published in English in peer-reviewed journals were included. RESULTS A total of 63 articles into 5 subchapters are presented: acute ischemic stroke (17), subarachnoid hemorrhage (14), brain trauma (14), intracranial hemorrhage (8), and mixed acute brain injury (10). This evidence confirm and extend the negative impact of hyperthermia in ABI patients on worse functional outcome and higher mortality. In particular "early hyperthermia" in AIS patients seems to have a protective role have as promoting factor of clot lysis but no conclusive evidence is available. Normothermic TTM seems to have a positive effect on TBI patients in a reduced mortality rate compared to hypothermic TTM. CONCLUSIONS Hyperthermia in ABI patients is associated with worse functional outcome and higher mortality. The use of normothermic TTM has an established indication only in TBI; further studies are needed to define the role and the indications of normothermic TTM in ABI patients.
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Affiliation(s)
- M Pegoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy.
| | - Z Zurlo
- Department of Anaesthesia and Intensive Care, University La Sapienza, Rome, Italy
| | - F Bilotta
- Department of Anaesthesia and Intensive Care, University La Sapienza, Rome, Italy
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Chang CP, Hsiao CT, Wang CH, Chen KH, Chen IC, Lin CN, Hsiao KY. Hyperglycemia as a positive predictor of mortality in major trauma. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920911254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Hyperglycemia in the acute phase after trauma is a stress response and a metabolic reflection in humans with injury, which could adversely affect outcome in trauma patients. In this study, we attempted to identify if hyperglycemia a reliable predictor for mortality in major trauma patients. Objectives: In order to identify if hyperglycemia a reliable predictor for mortality in major trauma, we designed and proformed a prospective observational study in a tertiary hospital. Method: We performed a prospective observational study to review the records of 601 patients with major trauma (injury severity scores >15) who visited our hospital’s emergency department from August 2012 to July 2015. Logistic regression was performed to assess the effect of hyperglycemia on mortality. Result: Major trauma patients in the hyperglycemia group had low systolic/diastolic blood pressure at triage, low initial Glasgow Coma Scale score, high incidence of hypotension episodes, coagulopathy, acidosis, and anemia. Hyperglycemia was significantly correlated with mortality in major trauma patients in this study (odds ratio: 1.97, 95% confidence interval: 1.04–3.74). Conclusion: In major trauma patients with injury severity scores >15, hyperglycemia has a positive correlation with mortality, which could be a predictor of mortality in clinical practice.
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Affiliation(s)
- Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi
- School of Medicine, Chang Gung University, Taoyuan
| | - Cheng-Hsien Wang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi
| | - Kai-Hua Chen
- School of Medicine, Chang Gung University, Taoyuan
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chiayi
| | - I-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi
- School of Medicine, Chang Gung University, Taoyuan
| | - Chun-Nan Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi
| | - Kuang-Yu Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi
- The Department of Optometry, Shu-Zen Junior College of Medicine and Management, Kaohsiung
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10
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Bain AR, Hoiland RL, Donnelly J, Nowak-Flück D, Sekhon M, Tymko MM, Greiner JJ, DeSouza CA, Ainslie PN. Cerebral metabolism, oxidation and inflammation in severe passive hyperthermia with and without respiratory alkalosis. J Physiol 2020; 598:943-954. [PMID: 31900940 DOI: 10.1113/jp278889] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 12/20/2019] [Indexed: 12/20/2022] Open
Abstract
KEY POINTS It was unknown whether respiratory alkalosis impacts the global cerebral metabolic response as well as the cerebral pro-oxidation and inflammatory response in passive hyperthermia. This study demonstrated that the cerebral metabolic rate was increased by ∼20% with passive hyperthermia of up to +2°C oesophageal temperature, and this response was unaffected by respiratory alkalosis. Additionally, the increase in cerebral metabolism did not significantly impact the net cerebral release of oxidative and inflammatory markers. These data indicate that passive heating of up to +2°C core temperature in healthy young men is not enough to confer a major oxidative and inflammatory burden on the brain, but it does markedly increase the cerebral metabolic rate, independently of P aC O 2 . ABSTRACT There is limited information concerning the impact of arterial P C O 2 /pH on heat-induced alteration in cerebral metabolism, as well as on the cerebral oxidative/inflammatory burden of hyperthermia. Accordingly, we sought to address two hypotheses: (1) passive hyperthermia will increase the cerebral metabolic rate of oxygen (CMRO2 ) consistent with a combined influence of Q10 and respiratory alkalosis; and (2) the net cerebral release of pro-oxidative and pro-inflammatory markers will be elevated in hyperthermia, particularly in poikilocapnic hyperthermia. Healthy young men (n = 6) underwent passive heating until an oesophageal temperature of 2°C above resting was reached. At 0.5°C increments in core temperature, CMRO2 was calculated from the product of cerebral blood flow (ultrasound) and the radial artery-jugular venous oxygen content difference (cannulation). Net cerebral glucose/lactate exchange, and biomarkers of oxidative and inflammatory stress were also measured. At +2.0°C oesophageal temperature, arterial P C O 2 was restored to normothermic values using end-tidal forcing. The primary findings were: (1) while CMRO2 was increased (P < 0.05) by ∼20% with hyperthermia of +1.5-2.0°C, this was not influenced by respiratory alkalosis, and (2) although biomarkers of pro-oxidation and pro-inflammation were systemically elevated in hyperthermia (P < 0.05), there were no differences in the trans-cerebral exchange kinetics. These novel data indicate that passive heating of up to +2°C core temperature in healthy young men is not enough to confer a major oxidative and inflammatory burden on the brain, despite it markedly increasing CMRO2 , irrespective of arterial pH.
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Affiliation(s)
- Anthony R Bain
- Faculty of Human Kinetics, University of Windsor, Windsor, Ontario, Canada
| | - Ryan L Hoiland
- Faculty of Health and Social Development, Center for Heart Lung and Vascular Health University of British Columbia, Kelowna, British Columbia, Canada
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | - Daniela Nowak-Flück
- Faculty of Health and Social Development, Center for Heart Lung and Vascular Health University of British Columbia, Kelowna, British Columbia, Canada
| | - Mypinder Sekhon
- Faculty of Health and Social Development, Center for Heart Lung and Vascular Health University of British Columbia, Kelowna, British Columbia, Canada.,Division of Critical Care Medicine and Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Michael M Tymko
- Faculty of Health and Social Development, Center for Heart Lung and Vascular Health University of British Columbia, Kelowna, British Columbia, Canada
| | - Jared J Greiner
- Department of Integrative Physiology, Integrative Vascular Biology Laboratory, University of Colorado, Boulder, CO, USA
| | - Christopher A DeSouza
- Department of Integrative Physiology, Integrative Vascular Biology Laboratory, University of Colorado, Boulder, CO, USA
| | - Philip N Ainslie
- Faculty of Health and Social Development, Center for Heart Lung and Vascular Health University of British Columbia, Kelowna, British Columbia, Canada
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11
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Hüser M, Kündig A, Karlen W, De Luca V, Jaggi M. Forecasting intracranial hypertension using multi-scale waveform metrics. Physiol Meas 2020; 41:014001. [PMID: 31851948 DOI: 10.1088/1361-6579/ab6360] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Acute intracranial hypertension is an important risk factor of secondary brain damage after traumatic brain injury. Hypertensive episodes are often diagnosed reactively, leading to late detection and lost time for intervention planning. A pro-active approach that predicts critical events several hours ahead of time could assist in directing attention to patients at risk. APPROACH We developed a prediction framework that forecasts onsets of acute intracranial hypertension in the next 8 h. It jointly uses cerebral auto-regulation indices, spectral energies and morphological pulse metrics to describe the neurological state of the patient. One-minute base windows were compressed by computing signal metrics, and then stored in a multi-scale history, from which physiological features were derived. MAIN RESULTS Our model predicted events up to 8 h in advance with an alarm recall rate of 90% at a precision of 30% in the MIMIC-III waveform database, improving upon two baselines from the literature. We found that features derived from high-frequency waveforms substantially improved the prediction performance over simple statistical summaries of low-frequency time series, and each of the three feature classes contributed to the performance gain. The inclusion of long-term history up to 8 h was especially important. SIGNIFICANCE Our results highlight the importance of information contained in high-frequency waveforms in the neurological intensive care unit. They could motivate future studies on pre-hypertensive patterns and the design of new alarm algorithms for critical events in the injured brain.
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Affiliation(s)
- Matthias Hüser
- Biomedical Informatics Group, Institute of Machine Learning, Department of Computer Science, ETH Zürich, 8092 Zürich, Switzerland
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12
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Bailey ZS, Cardiff K, Yang X, Gilsdorf J, Shear D, Rasmussen TE, Leung LY. The Effects of Balloon Occlusion of the Aorta on Cerebral Blood Flow, Intracranial Pressure, and Brain Tissue Oxygen Tension in a Rodent Model of Penetrating Ballistic-Like Brain Injury. Front Neurol 2019; 10:1309. [PMID: 31920932 PMCID: PMC6930175 DOI: 10.3389/fneur.2019.01309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/26/2019] [Indexed: 12/14/2022] Open
Abstract
Trauma is among the leading causes of death in the United States. Technological advancements have led to the development of resuscitative endovascular balloon occlusion of the aorta (REBOA) which offers a pre-hospital option to non-compressible hemorrhage control. Due to the prevalence of concomitant traumatic brain injury (TBI), an understanding of the effects of REBOA on cerebral physiology is critical. To further this understanding, we employed a rat model of penetrating ballistic-like brain injury (PBBI). PBBI produced an injury pattern within the right frontal cortex and striatum that replicates the pathology from a penetrating ballistic round. Aortic occlusion was initiated 30 min post-PBBI and maintained continuously (cAO) or intermittently (iAO) for 30 min. Continuous measurements of mean arterial pressure (MAP), intracranial pressure (ICP), cerebral blood flow (CBF), and brain tissue oxygen tension (PbtO2) were recorded during, and for 60 min following occlusion. PBBI increased ICP and decreased CBF and PbtO2. The arterial balloon catheter effectively occluded the descending aorta which augmented MAP in the carotid artery. Despite this, CBF levels were not changed by aortic occlusion. iAO caused sustained adverse effects to ICP and PbtO2 while cAO demonstrated no adverse effects on either. Temporary increases in PbtO2 were observed during occlusion, along with restoration of sham levels of ICP for the remainder of the recordings. These results suggest that iAO may lead to prolonged cerebral hypertension following PBBI. Following cAO, ICP, and PbtO2 levels were temporarily improved. This information warrants further investigation using TBI-polytrauma model and provides foundational knowledge surrounding the non-hemorrhage applications of REBOA including neurogenic shock and stroke.
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Affiliation(s)
- Zachary S Bailey
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Katherine Cardiff
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Xiaofang Yang
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Janice Gilsdorf
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Deborah Shear
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Todd E Rasmussen
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Lai Yee Leung
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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13
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Markedly Deranged Injury Site Metabolism and Impaired Functional Recovery in Acute Spinal Cord Injury Patients With Fever. Crit Care Med 2018; 46:1150-1157. [DOI: 10.1097/ccm.0000000000003134] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Huijben JA, Volovici V, Cnossen MC, Haitsma IK, Stocchetti N, Maas AIR, Menon DK, Ercole A, Citerio G, Nelson D, Polinder S, Steyerberg EW, Lingsma HF, van der Jagt M. Variation in general supportive and preventive intensive care management of traumatic brain injury: a survey in 66 neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:90. [PMID: 29650049 PMCID: PMC5898014 DOI: 10.1186/s13054-018-2000-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/19/2018] [Indexed: 12/20/2022]
Abstract
Background General supportive and preventive measures in the intensive care management of traumatic brain injury (TBI) aim to prevent or limit secondary brain injury and optimize recovery. The aim of this survey was to assess and quantify variation in perceptions on intensive care unit (ICU) management of patients with TBI in European neurotrauma centers. Methods We performed a survey as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. We analyzed 23 questions focused on: 1) circulatory and respiratory management; 2) fever control; 3) use of corticosteroids; 4) nutrition and glucose management; and 5) seizure prophylaxis and treatment. Results The survey was completed predominantly by intensivists (n = 33, 50%) and neurosurgeons (n = 23, 35%) from 66 centers (97% response rate). The most common cerebral perfusion pressure (CPP) target was > 60 mmHg (n = 39, 60%) and/or an individualized target (n = 25, 38%). To support CPP, crystalloid fluid loading (n = 60, 91%) was generally preferred over albumin (n = 15, 23%), and vasopressors (n = 63, 96%) over inotropes (n = 29, 44%). The most commonly reported target of partial pressure of carbon dioxide in arterial blood (PaCO2) was 36–40 mmHg (4.8–5.3 kPa) in case of controlled intracranial pressure (ICP) < 20 mmHg (n = 45, 69%) and PaCO2 target of 30–35 mmHg (4–4.7 kPa) in case of raised ICP (n = 40, 62%). Almost all respondents indicated to generally treat fever (n = 65, 98%) with paracetamol (n = 61, 92%) and/or external cooling (n = 49, 74%). Conventional glucose management (n = 43, 66%) was preferred over tight glycemic control (n = 18, 28%). More than half of the respondents indicated to aim for full caloric replacement within 7 days (n = 43, 66%) using enteral nutrition (n = 60, 92%). Indications for and duration of seizure prophylaxis varied, and levetiracetam was mostly reported as the agent of choice for both seizure prophylaxis (n = 32, 49%) and treatment (n = 40, 61%). Conclusions Practice preferences vary substantially regarding general supportive and preventive measures in TBI patients at ICUs of European neurotrauma centers. These results provide an opportunity for future comparative effectiveness research, since a more evidence-based uniformity in good practices in general ICU management could have a major impact on TBI outcome. Electronic supplementary material The online version of this article (10.1186/s13054-018-2000-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jilske A Huijben
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Neurosurgery, Office H-703, Erasmus MC Stroke Center and Brain Tumor Center, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maryse C Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Iain K Haitsma
- Department of Neurosurgery, Office H-703, Erasmus MC Stroke Center and Brain Tumor Center, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - David Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Suzanne Polinder
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - Hester F Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care and Erasmus MC Stroke Center, Erasmus Medical Center, Rotterdam, the Netherlands
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Ondruschka B, Rosinsky F, Trauer H, Schneider E, Dreßler J, Franke H. Drug- and/or trauma-induced hyperthermia? Characterization of HSP70 and myoglobin expression. PLoS One 2018; 13:e0194442. [PMID: 29566034 PMCID: PMC5864017 DOI: 10.1371/journal.pone.0194442] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 03/02/2018] [Indexed: 01/04/2023] Open
Abstract
Introduction Heat shock protein 70 (HSP70) expression could be discussed as an adaption that promotes repair and counteracts cell damage. Myoglobin is released upon muscle damage of several pathways. The purpose of the present study was to determine whether the expression of HSP70 in kidney, heart and brain and of myoglobin in the kidney were associated with the cause of death and the survival times after lethal intoxications with three of the drugs most widely used in our local area (Saxony, Germany) as well as after fatal traumatic brain injury (TBI). Methods We retrospectively collected kidney, heart and brain samples of 50 autopsy cases with toxicological proved lethal intoxication (main drugs methamphetamine, morphine, alcohol), 14 TBI cases and 15 fatalities with acute myocardial injury in age- and gender-matched compilations. Results Our main findings suggest that HSP70 is associated with hyperthermal and other stress factors of most cell populations. HSP70 expressions in kidney and heart muscle are useful for a differentiation between fatal intoxications and cases without toxicological influence (p < 0.05). There were significant differences in the cerebral expression patterns between methamphetamine- and morphine-associated deaths compared to alcohol fatalities (p < 0.05). An intensive staining of HSP70 in the pericontusional zone and the hippocampus after TBI (especially neuronal and vascular) was shown even after short survival times and may be useful as an additional marker in questions of vitality or wound age. A relevant myoglobin decoration of renal tubules was only shown for methamphetamine abuse in the study presented. Conclusion In sum, the immunohistochemical characteristics presented can be supportive for determining final death circumstances and minimal trauma survival times but are not isolated usefully for the detection of drug- or trauma-induced hyperthermia.
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Affiliation(s)
- Benjamin Ondruschka
- Institute of Legal Medicine, Medical Faculty, University of Leipzig, Leipzig, Germany
- * E-mail:
| | - Franziska Rosinsky
- Institute of Legal Medicine, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Heiner Trauer
- Institute of Legal Medicine, Medical Faculty, University of Leipzig, Leipzig, Germany
| | | | - Jan Dreßler
- Institute of Legal Medicine, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Heike Franke
- Rudolf Boehm Institute of Pharmacology and Toxicology, Medical Faculty, University of Leipzig, Leipzig, Germany
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Empfehlung zum Temperaturmanagement nach Atem-Kreislauf-Stillstand und schwerem Schädel-Hirn-Trauma im Kindesalter jenseits der Neonatalperiode. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0306-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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17
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Brenner S, Eich C, Rellensmann G, Schuhmann MU, Nicolai T, Hoffmann F. [Recommendation on temperature management after cardiopulmonary arrest and severe traumatic brain injury in childhood beyond the neonatal period : Statement of the German Society for Neonatology and Pediatric Intensive Care Medicine (GNPI) and the scientific Working Group for Paediatric Anaesthesia (WAKKA) of the German Society of Anaesthesiology and Intensive Care (DGAI)]. Anaesthesist 2017; 66:128-133. [PMID: 28091756 DOI: 10.1007/s00101-016-0256-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The available data on the effectiveness of therapeutic hypothermia in different patient groups are heterogeneous. Although the benefits have been proven for some collectives, recommendations for the use of hypothermia treatment in other groups are based on less robust data and conclusions by analogy. This article gives a review of the current evidence of temperature management in all age groups and based on this state of knowledge, recommends active temperature management with the primary aim of strict normothermia (36-36.5 °C) for 72 hours after cardiopulmonary arrest or severe traumatic brain injury for children beyond the neonatal period.
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Affiliation(s)
- S Brenner
- Neonatologie und pädiatrische Intensivmedizin, Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - C Eich
- Abteilung Anästhesie, Kinderintensiv- und Notfallmedizin, Kinder- und Jugendkrankenhaus AUF DER BULT, Hannover, Deutschland
| | - G Rellensmann
- Neonatologie und pädiatrische Intensivmedizin, Klinik für Kinder- und Jugendmedizin - Allgemeine Pädiatrie, Universitätsklinikum Münster, Münster, Deutschland
| | - M U Schuhmann
- Bereich Pädiatrische Neurochirurgie, Klinik für Neurochirurgie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - T Nicolai
- Interdisziplinäre Kinderintensivstation, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Klinikum der Universität München, München, Deutschland
| | - F Hoffmann
- Interdisziplinäre Kinderintensivstation, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Klinikum der Universität München, München, Deutschland
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Abstract
While our ability to detect and manage fever has evolved since its conceptualization in the 5(th) century BC, controversy remains over the best evidence-based practices regarding if and when to treat this physiologic derangement in the critically ill. There are two basic fields of thought: (I) fever should be suppressed because its metabolic costs outweigh its potential physiologic benefit in an already stressed host; vs. (II) fever is a protective adaptive response that should be allowed to run its course under most circumstances. The latter approach, sometime referred to as the "let it ride" philosophy, has been supported by several recent randomized controlled trials like that of Young et al. [2015], which are challenging earlier observational studies and may be pushing the pendulum away from the Pavlovian treatment response.
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Affiliation(s)
- Juliet J Ray
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Carl I Schulman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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