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Laughlin BW, Sugiura MH, Jenkins M, Chen CY, Drew KL. N 6-cyclohexyladenosine is better than meperidine and buspirone at suppressing metabolism during TTM32 but does not improve outcome after cardiac arrest. Exp Neurol 2024; 380:114891. [PMID: 39047808 DOI: 10.1016/j.expneurol.2024.114891] [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: 02/26/2024] [Revised: 06/26/2024] [Accepted: 07/21/2024] [Indexed: 07/27/2024]
Abstract
N6-clyclohexyladenosine (CHA) is an adenosine A1 receptor agonist that inhibits thermogenesis. Cardiovascular side effects however, limit use of CHA as a therapeutic. We and others have shown that this can be reversed by administering 8-p-(sulfophenyl)theophylline (8-SPT), a nonspecific antagonist that does not cross the BBB. Other evidence shows that CNS actions of CHA may contribute to bradycardia through enhanced vagal tone and other mechanisms. Here we test the hypothesis that 8-SPT pretreatment alone is sufficient to prevent hypotension caused by CHA. To test this hypothesis, we pretreated rats with 8-SPT alone, and in combination with other antagonists to test the hypothesis that direct action of CHA on the heart is the primary mechanism by which CHA induces bradycardia and hypotension. Results show that pretreatment with 8-SPT alone is not sufficient to prevent CHA-induced hypotension. Pretreatment with 8-SPT or atropine alone did not prevent the fall in mean arterial pressure (MAP) and heart rate (HR), however, pretreatment with 8-SPT (25 mg/kg) and atropine (1 mg/kg) 15 min before CHA (1 mg/kg) preserves MAP and HR baseline values after CHA administration. We next asked if blood pressure was managed during the transition into a hypometabolic state, would prolong CHA-mediated inhibition of metabolism after cardiac arrest improve outcome better than anti-shivering medications meperidine and buspirone. We found that CHA-mediated hypotension can be mitigated by pretreatment with atropine and 8-SPT. This combination administered after cardiac arrest facilitated temperature management and metabolic suppression better than meperidine and buspirone, however, did not improve survival.
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Affiliation(s)
- Bernard W Laughlin
- Center for Transformative Research in Metabolism, Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, AK, USA
| | - M Hoshi Sugiura
- Center for Transformative Research in Metabolism, Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, AK, USA
| | - Mackenzie Jenkins
- Center for Transformative Research in Metabolism, Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, AK, USA
| | - Chao-Yin Chen
- Department of Pharmacology, University of California Davis, Davis, California, USA
| | - Kelly L Drew
- Center for Transformative Research in Metabolism, Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, AK, USA.
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Rhim JK, Park JJ, Kim H, Jeon JP. Early and Prolonged Mild Hypothermia in Patients with Poor-Grade Subarachnoid Hemorrhage: A Pilot Study. Ther Hypothermia Temp Manag 2022; 12:229-234. [PMID: 36130134 DOI: 10.1089/ther.2022.0013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We assessed the feasibility of therapeutic early and prolonged mild hypothermia (MH) in patients with poor-grade subarachnoid hemorrhage (SAH). A retrospective pilot study was conducted for poor-grade SAH patients at two university hospitals from March 2015 to December 2018 who had received MH immediately after coil embolization and maintained a target temperature of 34-35°C for 5 days. A matched controlled design at a 1:2 ratio was used to compare MH therapy outcomes. The primary goal was to assess the two groups' severe functional outcomes at discharge defined as a modified Rankin Scale score of 4-6. The secondary aim was to assess mortality and severe vasospasm depending upon MH. A binary logistic regression analysis was performed to identify relevant risk factors for the outcomes. A total of 54 patients (18 with MH treatment and 36 without MH treatment) were included. Severe functional outcome was significantly decreased in poor-grade SAH patients with MH (n = 7, 38.9%) than those without MH (n = 25, 69.4%; p = 0.031). In patients treated with MH, mortality and severe vasospasm tended to be less common, although the difference was not statistically significant. A binary logistic regression analysis revealed that early and prolonged MH (odds ratio [OR] = 0.156, 95% confidence intervals [CI]: 0.037-0.644) and severe vasospasm (OR = 5.593, 95% CI: 1.372-22.812) were risk factors for severe functional outcomes. This study shows potential therapeutic effect of early and prolonged MH treatment in poor-grade SAH patients. A randomized controlled study with a large number of patients is warranted in the future.
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Affiliation(s)
- Jong-Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju, Republic of Korea
| | - Jeong Jin Park
- Department of Neurology, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Heungcheol Kim
- Department of Radiology, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Republic of Korea
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Kong T, You JS, Lee HS, Jeon S, Park YS, Chung SP. Optimal temperature in targeted temperature management without automated devices using a feedback system: A multicenter study. Am J Emerg Med 2022; 57:124-132. [DOI: 10.1016/j.ajem.2022.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 03/23/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022] Open
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Kuroda Y, Kawakita K. Targeted temperature management for postcardiac arrest syndrome. JOURNAL OF NEUROCRITICAL CARE 2020. [DOI: 10.18700/jnc.200001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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RBM3 promotes neurogenesis in a niche-dependent manner via IMP2-IGF2 signaling pathway after hypoxic-ischemic brain injury. Nat Commun 2019; 10:3983. [PMID: 31484925 PMCID: PMC6726629 DOI: 10.1038/s41467-019-11870-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 08/01/2019] [Indexed: 12/11/2022] Open
Abstract
Hypoxic ischemia (HI) is an acute brain threat across all age groups. Therapeutic hypothermia ameliorates resulting injury in neonates but its side effects prevent routine use in adults. Hypothermia up-regulates a small protein subset that includes RNA-binding motif protein 3 (RBM3), which is neuroprotective under stressful conditions. Here we show how RBM3 stimulates neuronal differentiation and inhibits HI-induced apoptosis in the two areas of persistent adult neurogenesis, the subventricular zone (SVZ) and the subgranular zone (SGZ), while promoting neural stem/progenitor cell (NSPC) proliferation after HI injury only in the SGZ. RBM3 interacts with IGF2 mRNA binding protein 2 (IMP2), elevates its expression and thereby stimulates IGF2 release in SGZ but not SVZ-NSPCs. In summary, we describe niche-dependent regulation of neurogenesis after adult HI injury via the novel RBM3-IMP2-IGF2 signaling pathway. Therapeutic hypothermia is a potent tool in the treatment of neonatal hypoxic-ischemic (HI) injury, yet the underlying mechanisms remain unclear. Here, authors demonstrate how the RNA-binding motif protein RBM3, which is induced by mild cooling while global translation rate is slowed down, contributes substantially to neuroregeneration after adult HI injury, specifically in the subventricular zone and subgranular zone.
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Zhang YW, Zhang J, Hu JQ, Wen CL, Dai SY, Yang DF, Li LF, Wu QB. Neuraxial adjuvants for prevention of perioperative shivering during cesarean section: A network meta-analysis following the PRISMA guidelines. World J Clin Cases 2019; 7:2287-2301. [PMID: 31531322 PMCID: PMC6718794 DOI: 10.12998/wjcc.v7.i16.2287] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/25/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Perioperative shivering is clinically common during cesarean sections under neuraxial anesthesia, and several neuraxial adjuvants are reported to have preventive effects on it. However, the results of current studies are controversial and the effects of these neuraxial adjuvants remain unclear.
AIM To evaluate the effects of neuraxial adjuvants on perioperative shivering during cesarean sections, thus providing an optimal choice for clinical application.
METHODS A systematic review and network meta-analysis were conducted following the PRISMA (Preferred Reported Items for Systematic Review and Meta-analysis) guidelines. Analyses were performed using Review Manager 5.3 and Stata 14.0. We searched PubMed, EMBASE, Web of Science, and Cochrane Central databases for eligible clinical trials assessing the effects of neuraxial adjuvants on perioperative shivering and other adverse events during cesarean sections. Perioperative shivering was defined as the primary endpoint, and nausea, vomiting, pruritus, hypotension, and bradycardia were the secondary outcomes.
RESULTS Twenty-six studies using 9 neuraxial adjuvants for obstetric anesthesia during caesarean sections were included. The results showed that, compared with placebo, pethidine, fentanyl, dexmedetomidine, and sufentanil significantly reduced the incidence of perioperative shivering. Among the four neuraxial adjuvants, pethidine was the most effective one for shivering prevention (OR = 0.15, 95%CI: 0.07-0.35, surface under the cumulative ranking curve 83.9), but with a high incidence of nausea (OR = 3.15, 95%CI: 1.04-9.57) and vomiting (OR = 3.71, 95%CI: 1.81-7.58). The efficacy of fentanyl for shivering prevention was slightly inferior to pethidine (OR = 0.20, 95%CI: 0.09-0.43), however, it significantly decreased the incidence of nausea (OR = 0.34, 95%CI: 0.15-0.79) and vomiting (OR = 0.25, 95%CI: 0.11-0.56). In addition, compared with sufentanil, fentanyl showed no impact on haemodynamic stability and the incidence of pruritus.
CONCLUSION Pethidine, fentanyl, dexmedetomidine, and sufentanil appear to be effective for preventing perioperative shivering in puerperae undergoing cesarean sections. Considering the risk-benefit profiles of the included neuraxial adjuvants, fentanyl is probably the optimal choice.
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Affiliation(s)
- Yi-Wei Zhang
- State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Macau 999078, China
- Faculty of Chinese Medicine, Macau University of Science and Technology, Macau 999078, China
| | - Juan Zhang
- Department of Anesthesiology, First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Jia-Qi Hu
- Department of Anesthesiology, First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
- Department of Pain, Zhejiang Provincial People's Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Chun-Lei Wen
- Department of Anesthesiology, First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Shu-Yang Dai
- Department of Anesthesiology, Ruian People's Hospital, Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Dan-Feng Yang
- Department of Anesthesiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Li-Fang Li
- Faculty of Chinese Medicine, Macau University of Science and Technology, Macau 999078, China
| | - Qi-Biao Wu
- State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Macau 999078, China
- Faculty of Chinese Medicine, Macau University of Science and Technology, Macau 999078, China
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Boulila C, Ben Abdallah S, Marincamp A, Coic V, Lauverjat R, Ericher N, Bougouin W, Mira JP, Cariou A, Geri G. Use of Neuromuscular Blockers During Therapeutic Hypothermia After Cardiac Arrest: A Nursing Protocol. Crit Care Nurse 2018; 36:33-40. [PMID: 27908944 DOI: 10.4037/ccn2016387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Neuromuscular blockers used to prevent shivering during therapeutic hypothermia in comatose patients after out-of-hospital cardiac arrest are associated with adverse events. OBJECTIVE To assess the influence of a nurse-implemented protocol on use of neuromuscular blockers in patients treated with 24-hour therapeutic hypothermia after out-of-hospital cardiac arrest. METHODS A before and after study was done in a 24-bed cardiac arrest center. During the before period, paralysis was maintained by continuous infusion of vecuronium during therapeutic hypothermia. During the after period, a nurse-implemented protocol was used to strictly control use of neuromuscular blockers. The primary outcome measure was duration of infusion of neuromuscular blockers; secondary end points included rates of ventilator-associated pneumonia and intensive care unit mortality. RESULTS Among the 22 patients in the before group and the 23 patients in the after group, most were men (78%) with a median age of 66 years. Baseline characteristics were similar between the 2 groups. Median duration of sedation was 36 hours, shorter in the after group (34 hours) than in the before group (38 hours; P = .02). Median duration of infusion of neuromuscular blockers was significantly shorter in the after group (6 hours) than in the before group (33 hours; P < .001). Ventilator-associated pneumonia occurred more frequently in the before group (45%) than in the after group (13%; P = .02). Overall intensive care unit mortality rate was 58%, similar in both groups (P = .44). CONCLUSION Use of a nurse-implemented protocol to reduce use of neuromuscular blockers is feasible.
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Affiliation(s)
- Coraline Boulila
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Samia Ben Abdallah
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Aude Marincamp
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Vincent Coic
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Romuald Lauverjat
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Nicole Ericher
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Wulfran Bougouin
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Jean-Paul Mira
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
| | - Alain Cariou
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France. .,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France. .,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University. .,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research. .,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.
| | - Guillaume Geri
- Coraline Boulila, Samia Ben Abdallah, Aude Marincamp, Vincent Coic, and Romuald Lauverjat are research nurses and Nicole Ericher is the charge nurse, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Wulfran Bougouin is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research, Paris, France.,Jean-Paul Mira is a critical care physician and head, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris and a professor of critical care medicine, Paris Descartes University.,Alain Cariou is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a professor of critical care medicine, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research.,Guillaume Geri is a critical care physician, medical intensive care unit, Cochin Hospital, Assistance Publique Hôpitaux de Paris, a clinical fellow, Paris Descartes University, and a scientist, Sudden Death Expertise Center, INSERM U970, Paris Cardiovascular Research
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Madden LK, Hill M, May TL, Human T, Guanci MM, Jacobi J, Moreda MV, Badjatia N. The Implementation of Targeted Temperature Management: An Evidence-Based Guideline from the Neurocritical Care Society. Neurocrit Care 2017; 27:468-487. [DOI: 10.1007/s12028-017-0469-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Choudhary RC, Jia X. Hypothalamic or Extrahypothalamic Modulation and Targeted Temperature Management After Brain Injury. Ther Hypothermia Temp Manag 2017; 7:125-133. [PMID: 28467285 PMCID: PMC5610405 DOI: 10.1089/ther.2017.0003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Targeted temperature management (TTM) has been recognized to protect tissue function and positively influence neurological outcomes after brain injury. While shivering during hypothermia nullifies the beneficial effect of TTM, traditionally, antishivering drugs or paralyzing agents have been used to reduce the shivering. The hypothalamic area of the brain helps in controlling cerebral temperature and body temperature through interactions between different brain areas. Thus, modulation of different brain areas either pharmacologically or by electrical stimulation may contribute in TTM; although, very few studies have shown that TTM might be achieved by activation and inhibition of neurons in the hypothalamic region. Recent studies have investigated potential pharmacological methods of inducing hypothermia for TTM by aiming to maintain the TTM and reduce the shivering effect without using antiparalytic drugs. Better survival and neurological outcome after brain injury have been reported after pharmacologically induced TTM. This review discusses the mechanisms and modulation of the hypothalamus with other brain areas that are involved in inducing hypothermia through which TTM may be achieved and provides therapeutic strategies for TTM after brain injury.
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Affiliation(s)
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Orthopedics, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Choi KE, Park B, Moheet AM, Rosen A, Lahiri S, Rosengart A. Systematic Quality Assessment of Published Antishivering Protocols. Anesth Analg 2017; 124:1539-1546. [PMID: 27622717 DOI: 10.1213/ane.0000000000001571] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Shivering is a common side effect of targeted temperature modulation and general anesthesia. Antishivering strategies often employ a stepwise approach involving both pharmacological and physical interventions. However, approaches to treat shivering are often empiric and vary widely across care environments. We evaluated the quality of published antishivering protocols and guidelines with respect to methodological rigor, reliability, and consistency of recommendations.Using 4 medical databases, we identified 4027 publications that addressed shivering therapy, and excluded 3354 due to lack of relevance. After applying predefined eligibility criteria with respect to minimal protocol standards, 18 protocols/guidelines remained. Each was assessed using a modified Appraisal of Guidelines for Research and Evaluation II (mAGREE II) instrument containing 23 quality items within 6 domains (maximal score 23). Among 18 protocols/guidelines, only 3 incorporated systematically reviewed recommendations, whereas 15 merely targeted practice standardization. Fifteen of 18 protocols/guidelines addressed shivering during therapeutic cooling in which skin counterwarming and meperidine were most commonly cited. However, their mAGREE II scores were within the lowest tertile (1 to 7 points) and the median for all 18 protocols was 5. The quality domains most commonly absent were stakeholder involvement, rigor of development, and editorial independence. Three of 18 protocols/guidelines addressed postanesthetic antishivering. Of these, the American Society of Anesthesiologists guidelines recommending forced-air warming and meperidine received the highest mAGREE II score (14 points), whereas the remaining 2 recommendations had low scores (<5 points).Current published antishivering protocols/guidelines lack methodological rigor, reliability, and strength, and even the highest scoring of the 18 protocols/guidelines fulfilled only 60% of quality items. To be consistent with evidence-based protocol/guideline development processes, future antishivering treatment algorithms should increase methodological rigor and transparency.
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Affiliation(s)
- Ko-Eun Choi
- From the Departments of *Neurology, †Neurosurgery, ‡Pharmacy, and §Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
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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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12
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Bailey IR, Laughlin B, Moore LA, Bogren LK, Barati Z, Drew KL. Optimization of Thermolytic Response to A 1 Adenosine Receptor Agonists in Rats. J Pharmacol Exp Ther 2017; 362:424-430. [PMID: 28652388 DOI: 10.1124/jpet.117.241315] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 06/22/2017] [Indexed: 12/13/2022] Open
Abstract
Cardiac arrest is a leading cause of death in the United States, and, currently, therapeutic hypothermia, now called targeted temperature management (TTM), is the only recent treatment modality proven to increase survival rates and reduce morbidity for this condition. Shivering and subsequent metabolic stress, however, limit application and benefit of TTM. Stimulating central nervous system A1 adenosine receptors (A1AR) inhibits shivering and nonshivering thermogenesis in rats and induces a hibernation-like response in hibernating species. In this study, we investigated the pharmacodynamics of two A1AR agonists in development as antishivering agents. To optimize body temperature (Tb) control, we evaluated the influence of every-other-day feeding, dose, drug, and ambient temperature (Ta) on the Tb-lowering effects of N6-cyclohexyladenosine (CHA) and the partial A1AR agonist capadenoson in rats. The highest dose of CHA (1.0 mg/kg, i.p.) caused all ad libitum-fed animals tested to reach our target Tb of 32°C, but responses varied and some rats overcooled to a Tb as low as 21°C at 17.0°C Ta Dietary restriction normalized the response to CHA. The partial agonist capadenoson (1.0 or 2.0 mg/kg, i.p.) produced a more consistent response, but the highest dose decreased Tb by only 1.6°C. To prevent overcooling after CHA, we studied continuous i.v. administration in combination with dynamic surface temperature control. Results show that after CHA administration control of surface temperature maintains desired target Tb better than dose or ambient temperature.
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Affiliation(s)
- Isaac R Bailey
- Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., L.A.M., L.K.B., Z.B., K.L.D.); and Departments of Chemistry and Biochemisty, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., K.L.D.)
| | - Bernard Laughlin
- Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., L.A.M., L.K.B., Z.B., K.L.D.); and Departments of Chemistry and Biochemisty, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., K.L.D.)
| | - Lucille A Moore
- Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., L.A.M., L.K.B., Z.B., K.L.D.); and Departments of Chemistry and Biochemisty, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., K.L.D.)
| | - Lori K Bogren
- Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., L.A.M., L.K.B., Z.B., K.L.D.); and Departments of Chemistry and Biochemisty, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., K.L.D.)
| | - Zeinab Barati
- Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., L.A.M., L.K.B., Z.B., K.L.D.); and Departments of Chemistry and Biochemisty, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., K.L.D.)
| | - Kelly L Drew
- Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., L.A.M., L.K.B., Z.B., K.L.D.); and Departments of Chemistry and Biochemisty, University of Alaska Fairbanks, Fairbanks, Alaska (I.R.B., B.L., K.L.D.)
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Nakashima R, Hifumi T, Kawakita K, Okazaki T, Egawa S, Inoue A, Seo R, Inagaki N, Kuroda Y. Critical Care Management Focused on Optimizing Brain Function After Cardiac Arrest. Circ J 2017; 81:427-439. [PMID: 28239054 DOI: 10.1253/circj.cj-16-1006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The discussion of neurocritical care management in post-cardiac arrest syndrome (PCAS) has generally focused on target values used for targeted temperature management (TTM). There has been less attention paid to target values for systemic and cerebral parameters to minimize secondary brain damage in PCAS. And the neurologic indications for TTM to produce a favorable neurologic outcome remain to be determined. Critical care management of PCAS patients is fundamental and essential for both cardiologists and general intensivists to improve neurologic outcome, because definitive therapy of PCAS includes both special management of the cause of cardiac arrest, such as coronary intervention to ischemic heart disease, and intensive management of the results of cardiac arrest, such as ventilation strategies to avoid brain ischemia. We reviewed the literature and the latest research about the following issues and propose practical care recommendations. Issues are (1) prediction of TTM candidate on admission, (2) cerebral blood flow and metabolism and target value of them, (3) seizure management using continuous electroencephalography, (4) target value of hemodynamic stabilization and its method, (5) management and analysis of respiration, (6) sedation and its monitoring, (7) shivering control and its monitoring, and (8) glucose management. We hope to establish standards of neurocritical care to optimize brain function and produce a favorable neurologic outcome.
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Affiliation(s)
- Ryuta Nakashima
- Department of Emergency and Critical Care Medicine, Oita City Medical Association's Almeida Memorial Hospital
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14
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Hannawi Y, Abers MS, Geocadin RG, Mirski MA. Abnormal movements in critical care patients with brain injury: a diagnostic approach. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:60. [PMID: 26975183 PMCID: PMC4791928 DOI: 10.1186/s13054-016-1236-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abnormal movements are frequently encountered in patients with brain injury hospitalized in intensive care units (ICUs), yet characterization of these movements and their underlying pathophysiology is difficult due to the comatose or uncooperative state of the patient. In addition, the available diagnostic approaches are largely derived from outpatients with neurodegenerative or developmental disorders frequently encountered in the outpatient setting, thereby limiting the applicability to inpatients with acute brain injuries. Thus, we reviewed the available literature regarding abnormal movements encountered in acutely ill patients with brain injuries. We classified the brain injury into the following categories: anoxic, vascular, infectious, inflammatory, traumatic, toxic-metabolic, tumor-related and seizures. Then, we identified the abnormal movements seen in each category as well as their epidemiologic, semiologic and clinicopathologic correlates. We propose a practical paradigm that can be applied at the bedside for diagnosing abnormal movements in the ICU. This model seeks to classify observed abnormal movements in light of various patient-specific factors. It begins with classifying the patient’s level of consciousness. Then, it integrates the frequency and type of each movement with the availability of ancillary diagnostic tests and the specific etiology of brain injury.
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Affiliation(s)
- Yousef Hannawi
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins University, Baltimore, MD, USA. .,Present address: Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University, Columbus, OH, USA.
| | - Michael S Abers
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Romergryko G Geocadin
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Marek A Mirski
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
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Figueroa SA, Leary M, Guanci MM, Mathiesen C, Delfin G, Bader MK. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2015; 5:235-9. [PMID: 26595142 DOI: 10.1089/ther.2015.29006.mkb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stephen A Figueroa
- 2 Division of Neurocritical Care, The University of Texas Southwestern Medical Center , Dallas, Texas
| | - Marion Leary
- 3 Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania , School of Nursing, Philadelphia, Pennsylvania
| | | | | | - Gail Delfin
- 6 Center for Resuscitation Science, University of Pennsylvania , Philadelphia, Pennsylvania
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Hegazy AF, Lapierre DM, Butler R, Althenayan E. Temperature control in critically ill patients with a novel esophageal cooling device: a case series. BMC Anesthesiol 2015; 15:152. [PMID: 26481105 PMCID: PMC4615396 DOI: 10.1186/s12871-015-0133-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 10/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mild hypothermia and fever control have been shown to improve neurological outcomes post cardiac arrest. Common methods to induce hypothermia include body surface cooling and intravascular cooling; however, a new approach using an esophageal cooling catheter has recently become available. METHODS We report the first three cases of temperature control using an esophageal cooling device (ECD). The ECD was placed in a similar fashion to orogastric tubes. Temperature reduction was achieved by connecting the ECD to a commercially available external heat exchange unit (Blanketrol Hyperthermia - Hypothermia System). RESULTS The first patient, a 54 year-old woman (86 kg) was admitted after resuscitation from an out-of-hospital non-shockable cardiac arrest. Shortly after admission, she mounted a fever peaking at 38.3 °C despite administration of cold intravenous saline and application of cooling blankets. ECD utilization resulted in a temperature reduction to 35.7 °C over a period of 4 h. She subsequently recovered and was discharged home at day 23. The second patient, a 59 year-old man (73 kg), was admitted after successful resuscitation from a protracted out-of hospital cardiac arrest. His initial temperature was 35 °C, but slowly increased to 35.8 °C despite applying a cooling blanket and ice packs. The ECD was inserted and a temperature reduction to 34.8 °C was achieved within 3 h. The patient expired on day 3. The third patient, a 47 year-old man (95 kg) presented with a refractory fever secondary to necrotizing pneumonia in the postoperative period after coronary artery bypass grafting. His fever persisted despite empiric antibiotics, antipyretics, cooling blankets, and ice packs. ECD insertion resulted in a decrease in temperature from 39.5 to 36.5 °C in less than 5 h. He eventually made a favorable recovery and was discharged home after 59 days. In all 3 patients, device placement occurred in under 3 min and ease-of-use was reported as excellent by nursing staff and physicians. CONCLUSIONS The esophageal cooling device was found to be an effective temperature control modality in this small case series of critically ill patients. Preliminary data presented in this report needs to be confirmed in large randomized controlled trials comparing its efficacy and safety to standard temperature control modalities.
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Affiliation(s)
- Ahmed F Hegazy
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, N6A 5A5, ON, Canada.
| | - Danielle M Lapierre
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, N6A 5A5, ON, Canada.
| | - Ron Butler
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, N6A 5A5, ON, Canada.
| | - Eyad Althenayan
- Department of Medicine, Division of Critical Care, University of Western Ontario, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, N6A 5A5, ON, Canada.
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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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18
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Therapeutic hypothermia post-cardiac arrest: a clinical nurse specialist initiative in Pakistan. CLIN NURSE SPEC 2015; 28:231-9. [PMID: 24911824 DOI: 10.1097/nur.0000000000000057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this project was to assess the feasibility of an evidence-based therapeutic hypothermia protocol in adult post-cardiac arrest (CA) patients in a university hospital in Pakistan. BACKGROUND Cardiac arrest has a deleterious effect on neurological function, and survival is associated with significant morbidity. The International Liaison Committee of Cardiopulmonary Resuscitation and the American Heart Association recommend the use of mild hypothermia in post-CA victims to mitigate brain injury caused by anoxia. In Pakistan, the survival rate in CA victims is poor. At present, there are no hospitals in the country that use the evidence-based hypothermia intervention in adult post-CA victims. DESCRIPTION This pilot project of therapeutic hypothermia in adult post-CA patients was implemented in a university hospital in Pakistan by a clinical nurse specialist in collaboration with the cardiopulmonary resuscitation committee and the nursing leadership of the hospital. Various clinical nurse specialist competencies and roles were used to address the 3 spheres of influence: patient, nurses, and system, while executing an evidence-based hypothermia protocol. Process and outcome indicators were monitored to evaluate the effectiveness and feasibility of hypothermia intervention in this setting. OUTCOME The hypothermia protocol was successfully implemented in 3 adult post-CA patients using cost-effective measures. All 3 patients were extubated within 72 hours after CA, and 2 patients were discharged home with good neurological outcome. CONCLUSION Adoption of an evidence-based hypothermia protocol for adult CA patients is feasible in the intensive care setting of a university hospital in Pakistan. IMPLICATIONS The process used in the project can serve as a road map to other hospitals in resource-limited countries such as Pakistan that are motivated to improve post-CA outcomes. This experience reveals that advanced practice nurses can be instrumental in translation of evidence into practice in a healthcare system in Pakistan.
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20
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Jinka TR, Combs VM, Drew KL. Translating drug-induced hibernation to therapeutic hypothermia. ACS Chem Neurosci 2015; 6:899-904. [PMID: 25812681 DOI: 10.1021/acschemneuro.5b00056] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Therapeutic hypothermia (TH) improves prognosis after cardiac arrest; however, thermoregulatory responses such as shivering complicate cooling. Hibernators exhibit a profound and safe reversible hypothermia without any cardiovascular side effects by lowering the shivering threshold at low ambient temperatures (Ta). Activation of adenosine A1 receptors (A1ARs) in the central nervous system (CNS) induces hibernation in hibernating species and a hibernation-like state in rats, principally by attenuating thermogenesis. Thus, we tested the hypothesis that targeted activation of the central A1AR combined with a lower Ta would provide a means of managing core body temperature (Tb) below 37 °C for therapeutic purposes. We targeted the A1AR within the CNS by combining systemic delivery of the A1AR agonist (6)N-cyclohexyladenosine (CHA) with 8-(p-sulfophenyl)theophylline (8-SPT), a nonspecific adenosine receptor antagonist that does not readily cross the blood-brain barrier. Results show that CHA (1 mg/kg) and 8-SPT (25 mg/kg), administered intraperitoneally every 4 h for 20 h at a Ta of 16 °C, induce and maintain the Tb between 29 and 31 °C for 24 h in both naïve rats and rats subjected to asphyxial cardiac arrest for 8 min. Faster and more stable hypothermia was achieved by continuous infusion of CHA delivered subcutaneously via minipumps. Animals subjected to cardiac arrest and cooled by CHA survived better and showed less neuronal cell death than normothermic control animals. Central A1AR activation in combination with a thermal gradient shows promise as a novel and effective pharmacological adjunct for inducing safe and reversible targeted temperature management.
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Affiliation(s)
- Tulasi R. Jinka
- University of Alaska Fairbanks, 902 North Koyukuk Drive, Fairbanks, Alaska 99775-7000, United States
- University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Velva M. Combs
- University of Alaska Fairbanks, 902 North Koyukuk Drive, Fairbanks, Alaska 99775-7000, United States
| | - Kelly L. Drew
- University of Alaska Fairbanks, 902 North Koyukuk Drive, Fairbanks, Alaska 99775-7000, United States
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Bader MK. Clinical Q & A: translating therapeutic temperature management from theory to practice. Ther Hypothermia Temp Manag 2015; 5:55-60. [PMID: 25692222 DOI: 10.1089/ther.2015.1503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bader MK, Guanci MM, Figueroa SA, Leary M, Baumann JJ, Livesay S, Ray TD. Clinical Q & A: Translating therapeutic temperature management from theory to practice. Ther Hypothermia Temp Manag 2014; 4:145-8. [PMID: 25078530 DOI: 10.1089/ther.2014.1510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Holzer M. Therapeutic hypothermia following cardiac arrest. Best Pract Res Clin Anaesthesiol 2014; 27:335-46. [PMID: 24054512 DOI: 10.1016/j.bpa.2013.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 07/23/2013] [Indexed: 11/19/2022]
Abstract
More than 10 years ago, the randomised studies of therapeutic hypothermia after cardiac arrest showed significant improvement of neurological outcome and survival. Since then, it has become clear that most of the possible adverse events of therapeutic hypothermia are mild and can easily be controlled by proper administration of intensive care. Although implementation of this effective therapy is quite successful, many questions of the exact treatment protocol still remain unanswered. Therapeutic hypothermia treatment therefore must be tailored to the specific patient's needs. Hence, the exact level of target temperature, duration of cooling, rewarming, timing of the therapy and concomitant medication to facilitate therapeutic hypothermia will be important in the future. Additionally, the use of a post-resuscitation treatment bundle (specialised cardiac-arrest centres including intensive post-resuscitation care, appropriate haemodynamic and respiratory management, therapeutic hypothermia and percutaneous coronary intervention) could further improve treatment of cardiac arrest.
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Affiliation(s)
- Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
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Madden CJ, Tupone D, Cano G, Morrison SF. α2 Adrenergic receptor-mediated inhibition of thermogenesis. J Neurosci 2013; 33:2017-28. [PMID: 23365239 PMCID: PMC3711400 DOI: 10.1523/jneurosci.4701-12.2013] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 11/21/2012] [Accepted: 11/26/2012] [Indexed: 01/01/2023] Open
Abstract
α2 adrenergic receptor (α2-AR) agonists have been used as antihypertensive agents, in the management of drug withdrawal, and as sedative analgesics. Since α2-AR agonists also influence the regulation of body temperature, we explored their potential as antipyretic agents. This study delineates the central neural substrate for the inhibition of rat brown adipose tissue (BAT) and shivering thermogenesis by α2-AR agonists. Nanoinjection of the α2-AR agonist clonidine (1.2 nmol) into the rostral raphe pallidus area (rRPa) inhibited BAT sympathetic nerve activity (SNA) and BAT thermogenesis. Subsequent nanoinjection of the α2-AR antagonist idazoxan (6 nmol) into the rRPa reversed the clonidine-evoked inhibition of BAT SNA and BAT thermogenesis. Systemic administration of the α2-AR agonists dexmedetomidine (25 μg/kg, i.v.) and clonidine (100 μg/kg, i.v.) inhibited shivering EMGs, BAT SNA, and BAT thermogenesis, effects that were reversed by nanoinjection of idazoxan (6 nmol) into the rRPa. Dexmedetomidine (100 μg/kg, i.p.) prevented and reversed lipopolysaccharide-evoked (10 μg/kg, i.p.) thermogenesis in free-behaving rats. Cholera toxin subunit b retrograde tracing from rRPa and pseudorabies virus transynaptic retrograde tracing from BAT combined with immunohistochemistry for catecholaminergic biosynthetic enzymes revealed the ventrolateral medulla as the source of catecholaminergic input to the rRPa and demonstrated that these catecholaminergic neurons are synaptically connected to BAT. Photostimulation of ventrolateral medulla neurons expressing the PRSx8-ChR2-mCherry lentiviral vector inhibited BAT SNA via activation of α2-ARs in the rRPa. These results indicate a potent inhibition of BAT and shivering thermogenesis by α2-AR activation in the rRPa, and suggest a therapeutic potential of α2-AR agonists for reducing potentially lethal elevations in body temperature during excessive fever.
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Affiliation(s)
- Christopher J Madden
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon 97239, USA.
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