Post on 16-Feb-2021
11
Target Temperature
management
龔瑞琛M.Sc., M.D.高醫神經外科2014-4-10 台東馬階
2
Mechanism of fever
http://www.google.com.tw/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=Pcmsqu2M7zWS2M&tbnid=GbX847y0P5JncM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.health32.com%2Fcat-scratch-fever-symptoms%2F&ei=n81eUqfDBce7iAfmnIG4Bw&psig=AFQjCNE5e1lcjzq6WdqvwBEAVctLosoexQ&ust=1382030878662313http://www.google.com.tw/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=Pcmsqu2M7zWS2M&tbnid=GbX847y0P5JncM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.health32.com%2Fcat-scratch-fever-symptoms%2F&ei=n81eUqfDBce7iAfmnIG4Bw&psig=AFQjCNE5e1lcjzq6WdqvwBEAVctLosoexQ&ust=1382030878662313
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http://biogeonerd.blogspot.tw/2012/10/brain.html
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Mink S. et al. Neurocritical care. 2010 ;DOI 10.1007/s12028-010-9451-1
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Summary of the beneficial and detrimental
effects of fever
Beneficial effects
On invading microorganism
Reduced growth/prolonged growth time
Increased antibiotic sensitivity/reducedminimal inhibitory concentration
Accelerated immune response
↑ Mobility of PMN cells
↑ Phagocytosis
↑ T-helper cell adherence
Prevention of lymphocytes cell reduction(CD4 T & B cells)
Attenuated immune response/protection against the collateral damage
↑ HSP causing a decrease of NF-κB ↓ TNFα and IFNγ
Detrimental effects
↑ Metabolic demand and oxygen consumption (myocardial and neurological injuries)
Source of patients’ discomfort?
Children’s seizures? (Controversial)
Collateral tissue damage?
Launey Y., et al. Critical care . 2011; 15: 222
6
Am J Respir Crit Care Med. 2012; 185: 1088–1095.
Fever control using external cooling in sedated patients with
septic shock is safe and decreases vasopressor requirement
and early mortality.
Multicenter RCT febrile patients
with septic shock requiring
vasopressors, mechanical ventilation,
and sedation
External cooling (n=101) to
achieve normothermia (36.5–37 oC)
for 48 hours or no external cooling (n
= 99).
7
Crit Care Nurse 2007;27:36-42
Evidence based Nursing Practice
8
Why the brain so important ?
“The cerebral cortex, the tissue most susceptible to hypoxia, is irreversibly damaged,
resulting in death or severe neurological
damage. The need to preserve cerebral vitality
must be stressed in research endeavors and in
practical interventions. The term
cardiopulmonary–cerebral resuscitation has
been used to further emphasize this need.”
Association AH. Guidelines 2000 for cardiopulmonary resuscitation
and emergency cardiovascular care; 2000.
9
Pathophysiology of hypoxic – ischemic
encephalopathy
• Common cause of global ischemia
- cardiac arrest or severe hypotension
- hypoglycemia
- sustaines seizures
• Global Ischemia
no circulation to remove the lactic &
other toxic metabolites
http://neuropathology-web.org/chapter2/chapter2aHIE.html
10
Nolan, J. P. et al. Nat. Rev. Cardiol.2012; 9: 499–511.
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http://www.google.com.tw/url?sa=i&rct=j&q=hypothermia%20therapy%20cardiac%20arrest&source=images&cd=&cad=rja&docid=dbsBuK3zK5jzaM&tbnid=xZVgR2UPOsT7GM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.hksccm.org%2Findex.php%3Foption%3Dcom_content%26view%3Darticle%26id%3D2102%3A2010-sep-24-induced-hypothermia-for-patients-with-cardiac-arrest%26catid%3D151%3Amiscellaneous%26Itemid%3D90&ei=BoEzUfq1I4mkkwW6-4DQBg&psig=AFQjCNE0QwvS24dPBAvj2y7J_umCS2SHjQ&ust=1362415503349412http://www.google.com.tw/url?sa=i&rct=j&q=hypothermia%20therapy%20cardiac%20arrest&source=images&cd=&cad=rja&docid=dbsBuK3zK5jzaM&tbnid=xZVgR2UPOsT7GM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.hksccm.org%2Findex.php%3Foption%3Dcom_content%26view%3Darticle%26id%3D2102%3A2010-sep-24-induced-hypothermia-for-patients-with-cardiac-arrest%26catid%3D151%3Amiscellaneous%26Itemid%3D90&ei=BoEzUfq1I4mkkwW6-4DQBg&psig=AFQjCNE0QwvS24dPBAvj2y7J_umCS2SHjQ&ust=1362415503349412http://www.google.com.tw/url?sa=i&rct=j&q=hypothermia%20therapy%20cardiac%20arrest&source=images&cd=&cad=rja&docid=8kZzDbU-GRssbM&tbnid=q25JDAloOBLSGM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.be.seas.upenn.edu%2Fabout-research%2Fug-research.php&ei=zIEzUYjjBsyBkwXF5YGYCw&psig=AFQjCNE0QwvS24dPBAvj2y7J_umCS2SHjQ&ust=1362415503349412http://www.google.com.tw/url?sa=i&rct=j&q=hypothermia%20therapy%20cardiac%20arrest&source=images&cd=&cad=rja&docid=8kZzDbU-GRssbM&tbnid=q25JDAloOBLSGM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.be.seas.upenn.edu%2Fabout-research%2Fug-research.php&ei=zIEzUYjjBsyBkwXF5YGYCw&psig=AFQjCNE0QwvS24dPBAvj2y7J_umCS2SHjQ&ust=1362415503349412http://www.google.com.tw/url?sa=i&rct=j&q=hypothermia%20therapy%20cardiac%20arrest&source=images&cd=&cad=rja&docid=w6TeLc29tMRl8M&tbnid=nWTa05be69Y7vM:&ved=0CAUQjRw&url=http%3A%2F%2Fondrowning.blogspot.com%2F2012%2F10%2Ftherapeutic-hypothermia-ultimate-brain.html&ei=q4EzUYbyDIrRlAW2poHoAw&psig=AFQjCNE0QwvS24dPBAvj2y7J_umCS2SHjQ&ust=1362415503349412http://www.google.com.tw/url?sa=i&rct=j&q=hypothermia%20therapy%20cardiac%20arrest&source=images&cd=&cad=rja&docid=w6TeLc29tMRl8M&tbnid=nWTa05be69Y7vM:&ved=0CAUQjRw&url=http%3A%2F%2Fondrowning.blogspot.com%2F2012%2F10%2Ftherapeutic-hypothermia-ultimate-brain.html&ei=q4EzUYbyDIrRlAW2poHoAw&psig=AFQjCNE0QwvS24dPBAvj2y7J_umCS2SHjQ&ust=1362415503349412
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• Hippocrates(希波克拉底) advocated the packing of
wounded soldiers in
snow and ice
• Napoleonic surgeon
Baron Dominque Larrey
wounded soldiers kept
further from the fire
better survival rates.12
13
Early experience…
• 1940 ~ 1960s – Cardiac arrest & TBI Hypothermia : metabolism reduction and
O2 / glucose demand decreased
• Cooling Slabs of ice, ice pads, Refrigerated water….or open window in winter
• Duration 2 ~ 10days
• Temperature < 30oC
13
Fay T: Observations on prolonged human
refrigeration. NY State J Med 1940; 40:
1351–1354
14
Fatality in hypothermia
−2 °C (28 °F)
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16
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Emergency Medical Service
EMCOOLS Flex.Pad must be placed and
precooled in a freezer at –8°C to –11°C.Hypocarbon© 3.5°C/Hr
http://www.google.com.tw/url?sa=i&rct=j&q=cardiac+arrest+pack+ice&source=images&cd=&cad=rja&docid=xKOlIaHEE4zSyM&tbnid=XEeL5dX031DcBM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.resuscitationcentral.com%2Fhypothermia%2Fcooling-techniques%2F&ei=jYUzUZTAGsOhlQWIl4DQCQ&psig=AFQjCNHZAbjSYvhPRb2WxY6KbJ1bKrqQhw&ust=1362417220252028http://www.google.com.tw/url?sa=i&rct=j&q=cardiac+arrest+pack+ice&source=images&cd=&cad=rja&docid=xKOlIaHEE4zSyM&tbnid=XEeL5dX031DcBM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.resuscitationcentral.com%2Fhypothermia%2Fcooling-techniques%2F&ei=jYUzUZTAGsOhlQWIl4DQCQ&psig=AFQjCNHZAbjSYvhPRb2WxY6KbJ1bKrqQhw&ust=1362417220252028
1818
Intracranial temperatureConclusion: Cerebral temperature was
relatively stable through the brain
parenchyma in this study. Because
intraventricular temperature accurately
reflects cerebral temperature, this is a
reasonable monitoring site for cerebral
temperature analysis
Ventricle
37.84 ± 1.03°C
Fountas k.N. Neurocritical Care. 2004; 1: 195
1919
Control fever after brain injury
• Nearly 47% patients developed fever (>38oC) in
NICU
Kilpatrick MM. et al. Neurosurgery. 2000; 47:850–885.
• Elevated temperature increases the morbidity
and mortality rates after ischemic and
hemorrhagic stroke, subarachnoidal hemorrhage
and head trauma
Schwab S. and Kollmar R. Neurocritical care. 2004; 1: 127
2020
Fever Control in Neuro-critical care
patients
• 2.2% ↑ in the risk of permanent disability or
mortality for every oC rise in BT
Reith J., et al. Lancet.1996; 347: 422–425.
• SAH, ICH, TBI & other neurological injuries
including cardiac arrest.
Factor 2.3/ ↑oC as >37 oC
Leira R., et al. Neurology. 2004; 63: 461–67.
Verlooy J., et al. Acta Neurochir. 1995; 134: 76–78.
Cairns CJ., et al. Curr Opin Crit Care. 2002; 8: 106–10.
Takino M, Okada Y. Intensive Care Med. 1991; 17: 419–20.
Diringer MN., et al. Crit Care Med. 2004; 32: 1611–12.
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Pathophysiology change in brain injury
with temperature
• ↑ Temperature ↑ glutamate toxicity
and diffusion
Suehiro E., et al. J of Neurotrauma. 1999;16: 285–297.
• Permeability of BBB ↑Worsening outcome
Sharma HS. & Hoopes PJ. Int J Hyperthermia.2003;19: 325–354.
Dietrich WD., et al. Neurosurgery. 1996; 8:533–541.
• After brain injury Brain To 15% >> Core To
Rossi S. et al., J Neuro Neurosurgery Psychi. 2001; 71:448–454.
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Pathophysiological change of fever
• Brain oT > core 2oC hyper-metabolism in
injured areas excitotoxic cascade and
inflammatory responseNybo L., et al. J Physiol. 2002; 545: 697–704.
Mellergard P., et al. Neurosurgery. 1991; 28: 709–13.
Schwab S., et al. Neurology. 1997; 48: 762–67.
• Cerebral thermopooling - excess heat as a
result of local edema formation and
vascular blockage.Polderman KH. Intensive Care Med. 2004; 30: 556–75.
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2323
Cooler
blood
Warmer
blood
heat
heat
heat
Mrozek S., et al. Anesthesiology Research and Practice.Vol. 2012, doi:10.1155/2012/989487
↑Metabolism
or stimuliCBF↑
http://www.google.com.tw/imgres?imgurl=http://www.cutmirchi.com/upimages/1357784352_healthy-heart1.jpg&imgrefurl=http://www.cutmirchi.com/viewdetails.php?linkid=29572&title=Diet's%2520Role%2520in%2520Lowering%2520Risk%2520of%2520Repeat%2520Heart%2520Attacks%2520-%2520WSJ.com%2520-%2520cutmirchi.com&usg=__6Pf7hqXVrFPFeNexrhtBN27M-kI=&h=1732&w=1732&sz=870&hl=zh-TW&start=112&zoom=1&tbnid=6pTcGeXmVuKEiM:&tbnh=150&tbnw=150&ei=kYzKUd2DC8jskgX66oDIBQ&prev=/search?q=heart&start=100&sa=N&hl=zh-TW&gbv=2&tbm=isch&itbs=1&sa=X&ved=0CEEQrQMwCzhkhttp://www.google.com.tw/imgres?imgurl=http://www.cutmirchi.com/upimages/1357784352_healthy-heart1.jpg&imgrefurl=http://www.cutmirchi.com/viewdetails.php?linkid=29572&title=Diet's%2520Role%2520in%2520Lowering%2520Risk%2520of%2520Repeat%2520Heart%2520Attacks%2520-%2520WSJ.com%2520-%2520cutmirchi.com&usg=__6Pf7hqXVrFPFeNexrhtBN27M-kI=&h=1732&w=1732&sz=870&hl=zh-TW&start=112&zoom=1&tbnid=6pTcGeXmVuKEiM:&tbnh=150&tbnw=150&ei=kYzKUd2DC8jskgX66oDIBQ&prev=/search?q=heart&start=100&sa=N&hl=zh-TW&gbv=2&tbm=isch&itbs=1&sa=X&ved=0CEEQrQMwCzhk
2424
Role of hypothermia in TBI patients
• Hypothermia control IICP ( Level I)
• Improved outcome & survival – if treat at
experience center with hypothermia
within hours & >48hrs (Level IIA)
• Initial hypothermia (33-35oC) – if
hemodynamically stable maintain
hypothermia is accepted (Level IIA)
24
Polderman KH. Lancet. 2008; 371: 1955–69
25
2626
Targeted Temperature Management (目標體溫處理)vs
Therapeutic Hypothermia (低體溫治療)
Nunnally ME., et al. Crit Care Med. 2011; 39
Complete temperature profile (To) – not “mild”,
“moderate” or “deep”
Therapeutic – not assumed generally
Hypothermia – not include normothermia
2727
簋街
2828
Aims on controlling temperature
Normothermia – control fever or
hyperthermia
Hypothermia in Neurological patients –
To control IICP
Hypothermia - vasospasm
Hypothermia in OHCA – Improve outcome
2929
Preparation of TTM
Training yourself – Indications, timing and update knowledge
Training your staffs– Young resident and Nurses How to deal with the complications and
technical problems
Hospital investment – Training the staff, Which types of cooling devices and associated tools
To set up your own management protocol
3030
Checklist need to do in hypothermia -1
1) Use cooling device with central feedback loop to control
temperature & core temperature measurements to guide
treatment.
2) Add cold fluids in induction phase in most patients. Use
pressure bag for administering cold fluid
3) Avoid hypovolemia and hypotension (cold diuresis)
4) Avoid electrolyte disorders (loss of K, Mg, P)
5) Avoid hyperglycemia (insulin resistance & decreased insulin
secretion)
6) Control shiveringPolderman KH., et al. Crit Care Med. 2009; 37: 1101
30
3131
Core temperature measurement(Continuous)
1. Intravesical
2. Esophagus
3. Rectal
4. Intravascular
Cooling devices
1. Endovascular
2. Surface
3. Intravascular
http://www.google.com.tw/url?sa=i&rct=j&q=shivering&source=images&cd=&cad=rja&docid=FP5D_wlf6gq1VM&tbnid=kaiIEl5anULboM:&ved=0CAUQjRw&url=http://www.clipartof.com/portfolio/pasoderholm/illustration/shivering-winter-toon-guy-hugging-himself-to-keep-warm-93476.html&ei=Lw42Uei4J4WjkwWNuYHYCQ&psig=AFQjCNHyeBxqQM8mtdUBHUr64iPjp2ApaQ&ust=1362583403984510http://www.google.com.tw/url?sa=i&rct=j&q=shivering&source=images&cd=&cad=rja&docid=FP5D_wlf6gq1VM&tbnid=kaiIEl5anULboM:&ved=0CAUQjRw&url=http://www.clipartof.com/portfolio/pasoderholm/illustration/shivering-winter-toon-guy-hugging-himself-to-keep-warm-93476.html&ei=Lw42Uei4J4WjkwWNuYHYCQ&psig=AFQjCNHyeBxqQM8mtdUBHUr64iPjp2ApaQ&ust=1362583403984510
3232
Surface cooling – Water circulating
cooling blanket
3333
Surface cooling – Arctic Sun®
33
3434
Endovascular cooling
34
3535Aiyagari V. and Diringer M.N. Neurocritical care. 2004; 1 : 211
Close
loop
cool
water
CoolGard 3000™ system.
35
3636
Endovascular or surface cooling?
36Gillies MA., et al. Resuscitation. 2010; 81: 1117–1122
3737
Prehospital Cooling fluids
• Infusion ice-cold Lactate ringer’s (for example,
30 ml/kg of cold fluids at 4~5 °C) decreases core temperature by approximately 1.5 °C
Crit Care Med. 2012; 40: 747-753
• Refrigerated Normal saline 20~30ml/Kg
reduced core T°C from 36.9 ± 1.9°C to34.6 ± 1.5°C at 30 minutes
Polderman KH. Critical Care Medicine. 2004;30:757-769.
3838
Checklist need to do in hypothermia -1
1) Use cooling device with central feedback loop to control
temperature & core temperature measurements to guide
treatment.
2) Add cold fluids in induction phase in most patients. Use
pressure bag for administering cold fluid
3) Avoid hypovolemia and hypotension (cold diuresis)
4) Avoid electrolyte disorders (loss of K, Mg, P)
5) Avoid hyperglycemia (insulin resistance & decreased
insulin secretion)
6) Control shiveringPolderman KH., et al. Crit Care Med. 2009; 37: 1101
38
3939
Glucose & insulin, Electrolyte
• Hypothermia Insulin sensitivity Hyperglycemia
P.S. vice-versa
• Hypothermia renal tubular & intracellular shift K+, Mg2+, PO4- lowering Keep K+ ≧4.0mmol/L, Mg2+ ≧1.0mmol/L,
PO4- ≧1.0mmol/L
• Rewarming K+
4040
Checklist need to do in hypothermia -1
1) Use cooling device with central feedback loop to control
temperature & core temperature measurements to guide
treatment.
2) Add cold fluids in induction phase in most patients. Use
pressure bag for administering cold fluid
3) Avoid hypovolemia and hypotension (cold diuresis)
4) Avoid electrolyte disorders (loss of K, Mg, P)
5) Avoid hyperglycemia (insulin resistance & decreased insulin
secretion)
6) Control shiveringPolderman KH., et al. Crit Care Med. 2009; 37: 1101
40
4141
Lopez M. et al. Anesthesiology 1994; 80:780–788
The core temperature thresholds for sweating,
vasoconstriction, and shivering in men and women.
4242
Physiological changes in cooling
• Shivering and cutaneous vasoconstriction
- increase metabolic/ W.O.B/ myocardial stress
suppress by
sedation/opiates/anesthetics
• Sedation / analgesic vasodilation,
more heat loss, increase rate of
temperature decreasing
43
Shivering
Badjatia N. et al. Stroke. 2008;39:3242-3247
To prevent oversedation
44
Why use BSAS?
• Score of 2 ~ 3 a resting energy
expenditure of 2303 ~ 3686 kcal/d
• Score of 0 to 1 who expended
1390 ~ 1730 kcal/d
Presciutti M., et al. Crit Care Nurse. 2012;32:33-42
http://www.google.com.tw/url?sa=i&rct=j&q=shivering&source=images&cd=&cad=rja&docid=FP5D_wlf6gq1VM&tbnid=kaiIEl5anULboM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.clipartof.com%2Fportfolio%2Fpasoderholm%2Fillustration%2Fshivering-winter-toon-guy-hugging-himself-to-keep-warm-93476.html&ei=Lw42Uei4J4WjkwWNuYHYCQ&psig=AFQjCNHyeBxqQM8mtdUBHUr64iPjp2ApaQ&ust=1362583403984510http://www.google.com.tw/url?sa=i&rct=j&q=shivering&source=images&cd=&cad=rja&docid=FP5D_wlf6gq1VM&tbnid=kaiIEl5anULboM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.clipartof.com%2Fportfolio%2Fpasoderholm%2Fillustration%2Fshivering-winter-toon-guy-hugging-himself-to-keep-warm-93476.html&ei=Lw42Uei4J4WjkwWNuYHYCQ&psig=AFQjCNHyeBxqQM8mtdUBHUr64iPjp2ApaQ&ust=1362583403984510
4545
Antishivering agent
Fentanyl
Propofol
Meperidine
Dexmedetomidine
Clonidine
Magnesium
http://www.google.com.tw/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=mznPr-2bSTPxPM&tbnid=5WZzYbQB_83cyM:&ved=0CAUQjRw&url=http%3A%2F%2Ftoonclips.com%2Fdesign%2F10416&ei=xs5eUqSZOuWBiQegrYCYBw&psig=AFQjCNFf1_eLpQNWdv0za-CZhX6s3GD4tw&ust=1382031343106681http://www.google.com.tw/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=mznPr-2bSTPxPM&tbnid=5WZzYbQB_83cyM:&ved=0CAUQjRw&url=http%3A%2F%2Ftoonclips.com%2Fdesign%2F10416&ei=xs5eUqSZOuWBiQegrYCYBw&psig=AFQjCNFf1_eLpQNWdv0za-CZhX6s3GD4tw&ust=1382031343106681
4646
Checklist need to do in hypothermia -2
7) Avoid skin damage/bedsores; skin vasoconstriction
8) Avoid/promptly treat infections (suppression of symptoms such
as fever and leukocytosis.
9) Use appropriate sedation and analgesia
10) Adjust ventilator settings (cooling causes O2 consumption and
CO2 production)
11) Adjust feeding rate (cooling decreases metabolism by 7% to
10% per °C decrease below 37°C)
12) Adjust drug dosage (drug clearance may change, including
clearance of sedatives/opiates/paralyzers; use bolus doses
during hypothermia induction phase, avoid high maintenance
doses)Polderman KH., et al. Crit Care Med. 2009; 37: 1101
46
Counter warming
http://www.google.com.tw/url?sa=i&rct=j&q=icu+%E7%83%A4%E7%87%88&source=images&cd=&cad=rja&docid=msu24STGX0VWqM&tbnid=k473WRJg-a6OGM:&ved=0CAUQjRw&url=http://www.tvbs.com.tw/news/news_list.asp?no=sunkiss20080114121234&&dd=2012/6/12%2520%25A4U%25A4%25C8%252002:18:09&ei=wRXLUcyVNoeClAXl_4DgDw&psig=AFQjCNETHgXIUUELR-KT6M6zTwEQh8tkyw&ust=1372350155908311http://www.google.com.tw/url?sa=i&rct=j&q=icu+%E7%83%A4%E7%87%88&source=images&cd=&cad=rja&docid=msu24STGX0VWqM&tbnid=k473WRJg-a6OGM:&ved=0CAUQjRw&url=http://www.tvbs.com.tw/news/news_list.asp?no=sunkiss20080114121234&&dd=2012/6/12%2520%25A4U%25A4%25C8%252002:18:09&ei=wRXLUcyVNoeClAXl_4DgDw&psig=AFQjCNETHgXIUUELR-KT6M6zTwEQh8tkyw&ust=1372350155908311
4747
Checklist need to do in hypothermia -2
7) Avoid skin damage/bedsores; skin vasoconstriction
8) Avoid/promptly treat infections (suppression of symptoms
such as fever and leukocytosis.
9) Use appropriate sedation and analgesia
10) Adjust ventilator settings (cooling causes O2 consumption and
CO2 production)
11) Adjust feeding rate (cooling decreases metabolism by 7% to
10% per °C decrease below 37°C)
12) Adjust drug dosage (drug clearance may change, including
clearance of sedatives/opiates/paralyzers; use bolus doses
during hypothermia induction phase, avoid high maintenance
doses)Polderman KH., et al. Crit Care Med. 2009; 37: 1101
47
4848
Hypothermia - ~50% pneumonia
48
49
Left lung Empyema
49
5050
Checklist need to do in hypothermia -2
7) Avoid skin damage/bedsores; skin vasoconstriction
8) Avoid/promptly treat infections (suppression of symptoms
such as fever and leukocytosis.
9) Use appropriate sedation and analgesia (muscle relaxant)
10) Adjust ventilator settings (cooling causes O2 consumption and
CO2 production)
11) Adjust feeding rate (cooling decreases metabolism by 7%
to 10% per °C decrease below 37°C) - ↓40% Kcal12) Adjust drug dosage (drug clearance may change, including
clearance of sedatives/opiates/paralyzers; use bolus doses
during hypothermia induction phase, avoid high maintenance
doses)Polderman KH., et al. Crit Care Med. 2009; 37: 1101
50
515151
Propofol / Midazolam
Fentanyl
Atracurium
5252
Checklist need to do in hypothermia -2
7) Avoid skin damage/bedsores; skin vasoconstriction
8) Avoid/promptly treat infections (suppression of symptoms such
as fever and leukocytosis.
9) Use appropriate sedation and analgesia (muscle relaxant)
10) Adjust ventilator settings (cooling causes O2 consumption
and CO2 production)
11) Adjust feeding rate (cooling decreases metabolism by 7% to
10% per °C decrease below 37°C)
12) Adjust drug dosage (drug clearance may change, including
clearance of sedatives/opiates/paralyzers; use bolus doses
during hypothermia induction phase, avoid high maintenance
doses)Polderman KH., et al. Crit Care Med. 2009; 37: 1101
52
5353
Metabolism & Blood gases
• Hypothermia metabolic rate ± 8% / - 1o
Core temp.
• O2 & Co2 production
Mechanical ventilator setting dynamically
Prevent hyperventilation
Cerebral vasoconstriction
• Check ABG 37oC may cause misinterpret
5454
Estimate ABG at 35oC
Subtract 5 mm Hg PO2 / 1°C that thepatient’s temperature is 37°C
Subtract 2 mm Hg PCO2/ 1°C that thepatient’s temperature is 37°C
Add 0.012 pH units / 1°C that the patient’s temperature is 37°C.
If a patient’s ABG at 33°C analyzed at 37°C= pH 7.45, PCO2 35 mm Hg, and PO2 80 mm Hg
temperature-corrected pH 7.50, PCO2 27 mm Hg,PO2 60 mm Hg.
5555
Checklist need to do in hypothermia -2
7) Avoid skin damage/bedsores; skin vasoconstriction
8) Avoid/promptly treat infections (suppression of symptoms such
as fever and leukocytosis.
9) Use appropriate sedation and analgesia (muscle relaxant)
10) Adjust ventilator settings (cooling causes O2 consumption and
CO2 production)
11) Adjust feeding rate (cooling decreases metabolism by 7% to
10% per °C decrease below 37°C)
12) Adjust drug dosage (drug clearance may change, including
clearance of sedatives/opiates/paralyzers; use bolus doses
during hypothermia induction phase, avoid high
maintenance doses)Polderman KH., et al. Crit Care Med. 2009; 37: 1101
55
5656
Checklist need to do in hypothermia -3
13) Don’t let core temperature fall below 30°C (risk of arrhythmias arises at temp
5757
Coagulopathy
•
585858
Continuous EEG
5959
Non convulsive status epilepticus -
Hypothermia
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Left fronto-temporal contusions63y/o , ICP = 40mmHg TTM = 33oC
61
Undergo TTM – 33oC , Valporic acid use only
62
Post craniectomy D3
63
Undergo TTM – 33oC – shift to Meropenem, Levetiracetam
1000mg q12h
6464
How to create your own protocol?
Patient’s indication – ICP? Timing? Ref.?
Devices – Endovascular or surface
Target temperature – 33~35~37oC
Medications :
Sedation, Analgesic, Paralytics
Antibiotics
Anti-epileptic drugs (AED)
6565
How to create your own protocol?
Check lab data – Frequency? Types?
eg CBC + DC, Electorlyte, Renal function
Electrolytes replacement – K+
Shivering – Medication? Physical?
Chest caring – Physical? Medication?
Cooling period –
Induction maintanence Re-warming
6666
Phases of hypothermia.
Scirica B M Circulation 2013;127:244-250
Copyright © American Heart Association
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Take home messages
Indications – Fever, IICP, OHCA ?Target temperature oC ?
How long ? How cold? How fast of rewarm?
Complication – Infection, electrolyte imbalance, metabolic disturbance
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