Little benefit from mild hypothermia therapy for severely head injured patients with low intracranial pressure

Shiozaki, Tadahiko; Kato, Aitaro; Taneda, Mamoru; Hayakata, Toshiaki; Hashiguchi, Naoyuki; Tanaka, Hiroshi; Shimazu, Takeshi; Sugimoto, Hisashi

doi:10.3171/jns.1999.91.2.0185

Cited by 101 publications

(36 citation statements)

References 24 publications

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“…2 However, the rewarming period seems to be a critical phase, as has been observed in clinical studies and animal experiments. 2,4,5 In the present study, slower rewarming correlated with slower increase in ICP elevations and slower decrease in CPP. Several studies 6 -8 experiences suggest that metabolic mechanisms, which occur along the ischemic cascade and lead to edema formation, are interrupted or at least slowed down by moderate hypothermia.…”

Section: Discussionmentioning

confidence: 63%

“…5 Controlled rewarming in the present study consists of an active slowing down of passive rewarming by intermittent surface cooling with the use of cooling blankets and mattresses. Because controlling the temperature deviation around the target increase in temperature is important, this procedure needs to be performed by a well-trained nursing staff.…”

Section: Discussionmentioning

confidence: 99%

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Effect and Feasibility of Controlled Rewarming After Moderate Hypothermia in Stroke Patients With Malignant Infarction of the Middle Cerebral Artery

Steiner

Friede

Aschoff

et al. 2001

Stroke

128

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Background and Purpose-Moderate hypothermia has been found to reduce intracranial pressure (ICP) significantly in patients who have severe middle cerebral artery infarction. However, during passive rewarming, ICP continuously rises and some patients suffer transtentorial herniation. Methods-We investigated the question of whether slower rewarming leads to slower increase in ICP and slower decrease in cerebral perfusion pressure (CPP). Furthermore, we studied feasibility of slow, controlled rewarming. ICP, CPP, and core body temperature were monitored continuously. Achievement of rewarming protocol was assessed by hit rate of temperature target intervals. Side effects of hypothermia were assessed. Results-Rates of change of both ICP and CPP were correlated significantly with increase in temperature (ICP rϭ0.62, Pϭ0.002; CPP rϭϪ0.50, Pϭ0.017). In feasibility analysis of 13 controlled rewarmed patients, hit rate of temperature target intervals was 63% (median; range 48% to 81%); hit rate within the target interval or below was 79% (median; range 62% to 94%). Conclusions-Slow, controlled rewarming is feasible and may be used for ICP and CPP control after moderate hypothermia for space-occupying infarction. Key Words: stroke, ischemic Ⅲ brain edema Ⅲ intracranial pressure Ⅲ hypothermia A bout 3% to 10% of patients with middle cerebral artery (MCA) territory infarction develop space-occupying hemispheric edema with increases in intracranial pressure (ICP), subsequent transtentorial herniation, and brain stem compression. 1 Moderate hypothermia (body temperature 32°C to 33°C for 48 to 72 hours) has been found to reduce ICP significantly in these patients. 2 However, during rewarming, ICP continuously rises and some patients suffer transtentorial herniation.Until 1998, rewarming took place in a passive manner; ie, after hypothermia, the cooling system was stopped and the rewarming process ensued without induction of any cooling or rewarming device within the next 17 to 24 hours (median 18 hours). 2 We refer to this rewarming protocol as "passive rewarming." To address the question of whether prolonged and controlled rewarming would lower risk of critical rewarming, we studied modified controlled rewarming. Feasibility of the protocol was analyzed by hit rates of the target interval (HTI) for the temperature. Subjects and MethodsWe studied a consecutive series of 15 patients with malignant MCA infarction who underwent therapeutic hypothermia for 72 hours.Patients with any previous disabling neurological diseases or terminal illness were excluded from the protocol, which was approved by the local ethics committee. "Controlled rewarming" was defined as an increase in temperature of 0.1°C to 0.2°C over 2 to 4 hours ( Figure 1) and was achieved by actively slowing down the process of passive rewarming. The cooling blanket (Polar Bair, Augustine Medical) or mattress (Hico-Variotherm 530, Hirtz) was switched on and off to achieve the planned increase in temperature. ICP, cerebral perfusion pressure (CPP), and core temperature...

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Section: Discussionmentioning

confidence: 63%

Section: Discussionmentioning

confidence: 99%

Effect and Feasibility of Controlled Rewarming After Moderate Hypothermia in Stroke Patients With Malignant Infarction of the Middle Cerebral Artery

Steiner

Friede

Aschoff

et al. 2001

Stroke

128

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“…Ultimately, 13 trials met our inclusion criteria and were included in this review (Aibiki et al, 2000;Clifton et al, 1992Clifton et al, , 1993Clifton et al, , 2001Hirayama et al, 1994;Jiang et al, 2000;Liu et al, 2006;Marion et al, 1997;Qiu et al, 2005;Yan and Tang, 2001;Zhi et al, 2003;Shiozaki et al, 2001;Shiozaki et al, 1999). Table 1 describes characteristics of all included trials.…”

Section: Overviewmentioning

confidence: 99%

Hypothermia Treatment for Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Peterson

Carson

Carney

2008

Journal of Neurotrauma

256

188

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In this study, we conducted an updated meta-analysis of the effects of hypothermia therapy on mortality, favorable neurologic outcome, and associated adverse effects in adults with traumatic brain injury (TBI) for use by Brain Trauma Foundation (BTF)/American Association of Neurological Surgeons (AANS) task force to develop evidence-based treatment guidelines. Our data sources relied on handsearches of four previous good-quality systematic reviews, which all conducted electronic searches of primarily MEDLINE (OVID), EMBASE, and Cochrane Library. An independent, supplemental electronic search of MEDLINE was undertaken as well (last searched June 2007). Only English-language publications of randomized controlled trials of therapeutic hypothermia in adults with TBI were selected for analysis. Two reviewers independently abstracted data on trial design, patient population, hypothermia and cointervention protocols, patient outcomes, and aspects of methodological quality. Pooled relative risks (RR) and associated 95% confidence intervals (CIs) were calculated for each outcome using random-effects models. In the current study, only 13 trials met eligibility criteria, with a total of 1339 randomized patients. Sensitivity analyses revealed that outcomes were influenced by variations in methodological quality. Consequently, main analyses were conducted based on eight trials that demonstrated the lowest potential for bias (n = 781). Reductions in risk of mortality were greatest (RR 0.51; 95% CI 0.33, 0.79) and favorable neurologic outcomes much more common (RR 1.91; 95% CI 1.28, 2.85) when hypothermia was maintained for more than 48 h. However, this evidence comes with the suggestion that the potential benefits of hypothermia may likely be offset by a significant increase in risk of pneumonia (RR 2.37; 95% CI 1.37, 4.10). In sum, the present study's updated meta-analysis supports previous findings that hypothermic therapy constitutes a beneficial treatment of TBI in specific circumstances. Accordingly, the BTF/AANS guidelines task force has issued a Level III recommendation for optional and cautious use of hypothermia for adults with TBI.

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“…Scant literature exists regarding the rate of safe re-warming to minimize this risk. In the traumatic brain injury literature, rewarming rates of between 1°C/h and 1°C/day have been reported [22,45,49], and most of the preliminary reports of hypothermia in ALF patients have not included details of the rate of re-warming. Consequently, it would seem prudent to re-warm patients with ALF slowly, perhaps 1°C every 12 h.…”

Section: How Fast Should Hypothermic Patients Be Re-warmed?mentioning

confidence: 97%

Therapeutic Hypothermia for Acute Liver Failure: Toward a Randomized, Controlled Trial in Patients with Advanced Hepatic Encephalopathy

et al. 2008

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Acute liver failure (ALF), the abrupt loss of liver function in a patient without previous liver disease, remains a highly mortal condition. Patients with ALF often succumb to their liver injury after the development of cerebral edema, resulting in intracranial hypertension and brain herniation. While the management of cerebral edema in ALF always includes the administration of osmotically active agents, osmotherapy often reduces intracranial pressure (ICP) insufficiently, such that herniation may be delayed but not prevented. Therapeutic hypothermia, the intentional reduction of body core temperature, has been increasingly used to treat cerebral edema in patients with traumatic and hypoxic brain injury. Data in animal models of ALF also suggest that hypothermia is effective in the prevention and treatment of cerebral edema, and case reports in humans have suggested that hypothermia is an effective bridge to orthotopic liver transplantation. A randomized, controlled trial comparing the management of ALF patients under normothermic and hypothermic conditions is a logical extension of these preliminary observations. Herein, we consider the many difficulties which will be encountered in the design of such a trial in patients with ALF at high risk of developing cerebral edema.

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Little benefit from mild hypothermia therapy for severely head injured patients with low intracranial pressure

Abstract: The authors recommend normothermia therapy for the treatment of severely head injured patients in whom ICP can be maintained at lower than 20 mm Hg by using conventional therapies, because mild hypothermia therapy does not convey any advantage over normothermia therapy in such patients.

Cited by 101 publications

References 24 publications

Effect and Feasibility of Controlled Rewarming After Moderate Hypothermia in Stroke Patients With Malignant Infarction of the Middle Cerebral Artery

Effect and Feasibility of Controlled Rewarming After Moderate Hypothermia in Stroke Patients With Malignant Infarction of the Middle Cerebral Artery

Hypothermia Treatment for Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Therapeutic Hypothermia for Acute Liver Failure: Toward a Randomized, Controlled Trial in Patients with Advanced Hepatic Encephalopathy

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