Targeted temperature management in the ICU: guidelines from a French expert panel

Abstract

Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term “targeted temperature management” (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d’Anesthésie Réanimation [SFAR]) with the participation of the French Emergency Medicine Association (Société Française de Médecine d’Urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe Francophone de Réanimation et Urgences Pédiatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association Nationale de Neuro-Anesthésie Réanimation Française [ANARLF]), and the French Neurovascular Society (Société Française Neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts’ opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.

Targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke: consensus recommendations

“…Guidelines from a French expert panel, whilst recommending a core-temperature measurement for TTM in ICUs, failed to indicate specific sites. 12 Oesophageal or bladder probes are recommended for temperature measurement during TTM after a neurological injury by recent guidelines from the US Neurocritical Care Society (NCS), which also suggest a preference for continuous monitoring. 5 The Delphi participants' recommendations for sites of temperature measurement were split between two non-gold standard sites: the oesophagus and the rectum.…”

“…From the literature, it is difficult to discern the evidence for reactive TTM norm to manage neurogenic fever from the data published on the use of prophylactic TTM norm or TTM hypo for neuroprotection in TBI and stroke. 5,12,14,15 Overall, the panel felt that the evidence for TTM hypo in patients with neurogenic fever in ICH, SAH, and AIS was poor, and that, on balance, hypothermia could be associated with negative outcomes. The panel, therefore, recommended TTM norm for these patients, and hence, the focus of this paper.…”

“…The agreed cut-off of for the consensus was 70% of experts in agreement; this was in keeping with recent consensus initiatives in this field. 12…”

Management of Intracranial Pressure in Traumatic Brain Injury

“…While the biochemical mechanism of this observation is not understood, what is understood is that immediate elimination of the infection is required for a successful recovery. This unexplained fever is often called "neurological fever," and unlike a fever caused by a cold or viral infection, neurological fever tremendously increases metabolic demand [71]. In patients with GCS scores less than or equal to 8 with imaging that demonstrates signs of cerebral edema, placement of external ventricular drain in a sterile fashion is recommended to allow CSF drainage.…”

Therapeutische Hypothermie in der Neurointensivmedizin

“…Das primäre Outcome war dabei gutes funktionelles Outcome nach 90 Tagen.Aus den vorliegenden Studien zum Schädel-Hirn-Trauma, zur zerebralen Ischämie, zur SAB und zur ICB lässt sich ableiten, dass die therapeutische Hypothermie sicherlich einen relevanten Stellenwert hat in der Kontrolle kritisch erhöhter ICP-Werte bzw. des Hirnödems[21]. Die medikamentösen Optionen zur ICP-Kontrolle sind im Wesentlichen beschränkt auf die Gabe von Osmotherapeutika wie Mannitol und hypertone Kochsalzlösung.…”