Implementing a Stepwise Shivering Protocol During Targeted Temperature Management

Background: Shivering is often encountered in patients undergoing targeted temperature management (TTM) after cardiac arrest. The most efficient, safe way to prevent shivering during TTM is not clearly defined. Objective: The purpose of this study was to evaluate the impact of shivering management using a stepwise shivering protocol on time to target temperature (TT), medication utilization and nursing confidence. Methods: Single-center, retrospective chart review of all post-cardiac arrest patients who underwent TTM between 2016 and 2021. The primary outcome is a comparison of time to TT pre- and post-protocol implementation. Secondary objectives compared nursing confidence and medication utilization pre- and post-shivering protocol implementation. Results: Fifty-seven patients were included in the pre-protocol group and thirty-seven were in the post-protocol group. The median (IQR) time to TT was 195 (250) minutes and 165 (170), respectively (p = 0.190). The average doses of acetaminophen was 285 mg pre- vs 1994 mg post- (p <0.001, buspirone 47 mg pre- vs 127 mg post- (p < 0.001), magnesium 0.9 g pre-vs 2.8 g post- (p < 0.001), and fentanyl 1564 mcg pre- vs 2286 mcg post- (p=0.023). No difference was seen for midazolam and cisatracurium. Nurses reported feeling confident with his/her ability to manage shivering during TTM 38.5% of the time pre-protocol compared to 60% post-protocol (p = 0.306). Conclusion: Implementation of a stepwise approach to prevent and treat shivering improved time to TT in our institution, although this finding was not statistically significant. The stepwise protocol supported a reduced amount of high-risk medication use and increased nursing confidence in shivering management.

Influences of altered phytohormone use on endogenous ABA and mRNA populations during white spruce (Picea glauca) somatic embryo culture

We examined endogenous abscisic acid [(+)-ABA] amounts and mRNA populations in white spruce (Picea glauca (Moench) Voss) somatic embryos in liquid suspension culture during a pretreatment prior to induction of maturation with exogenous (+)-ABA. The pretreatment consisted of removal of 2,4-dichlorophenoxyacetic acid (2,4-D) from the multiplication medium for 7 days. The removal of 2,4-D resulted in a slight increase in endogenous ABA in pretreated tissues compared to nonpretreated tissues at the end of the 7-day pretreatment period (42.4 versus 20.0 pg mg(-1) lyophilized tissue). Altered gene expression patterns were observed as early as one day after the start of the pretreatment, with more than 17 new polypeptides found in pretreated tissues. The influence of pretreatment continued to be observed after tissues were transferred to ABA-containing maturation medium. By comparing mRNA populations in pretreated and nonpretreated tissues cultured on either ABA-containing or ABA-free maturation medium, at least 12 mRNAs were observed to be induced by ABA, among which three polypeptides were ABA inducible only in pretreated tissues.