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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

3

http://biogeonerd.blogspot.tw/2012/10/brain.html

4

Mink S. et al. Neurocritical care. 2010 ;DOI 10.1007/s12028-010-9451-1

5

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)

17

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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2121

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.

2222

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.

22

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

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

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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




treatment.





5) Avoid hyperglycemia (insulin resistance & decreased

insulin secretion)


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




treatment.





5) Avoid hyperglycemia (insulin resistance & decreased insulin

secretion)


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

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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

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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



8) Avoid/promptly treat infections (suppression of symptoms

such as fever and leukocytosis.

9) Use appropriate sedation and analgesia


CO2 production)







47

4848

Hypothermia - ~50% pneumonia

48

49

Left lung Empyema

49

5050



8) Avoid/promptly treat infections (suppression of symptoms

such as fever and leukocytosis.

9) Use appropriate sedation and analgesia (muscle relaxant)


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




50

515151

Propofol / Midazolam

Fentanyl

Atracurium

5252






10) Adjust ventilator settings (cooling causes O2 consumption

and CO2 production)







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







CO2 production)





during hypothermia induction phase, avoid high

maintenance doses)Polderman KH., et al. Crit Care Med. 2009; 37: 1101

55

5656


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

60

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

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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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Target Temperature - ttw3.mmh.org.twttw3.mmh.org.tw/neuroweb/pdf_files/2014-4-10 Target... · 20...

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