The Brain and Hypothermia—From Aristotle to Targeted Temperature Management

Kochanek, Patrick M.; Jackson, T. L.

doi:10.1097/ccm.0000000000002182

Cited by 21 publications

(12 citation statements)

References 57 publications

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“…Of note, barbiturate treatment, a potential confounder and independent neuroprotectant, was used more frequently in the standard care group. Similar to cardiac arrest, questions remain regarding the appropriate degree of hypothermia versus targeted temperature management, versus “ultra-mild” hypothermia that may provide neuroprotection beyond fever prevention [63, 64]. There are no BTF recommendations regarding hypothermia for ICP control in adults, but there is a level 2 recommendation in children [65].…”

Section: Cerebral Edema and Intracranial Pressurementioning

confidence: 99%

A Precision Medicine Approach to Cerebral Edema and Intracranial Hypertension after Severe Traumatic Brain Injury: Quo Vadis?

Jha

Kochanek

2018

Curr Neurol Neurosci Rep

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Purpose of Review Standard clinical protocols for treating cerebral edema and intracranial hypertension after severe TBI have remained remarkably similar over decades. Cerebral edema and intracranial hypertension are treated interchangeably when in fact intracranial pressure (ICP) is a proxy for cerebral edema but also other processes such as extent of mass lesions, hydrocephalus, or cerebral blood volume. A complex interplay of multiple molecular mechanisms results in cerebral edema after severe TBI, and these are not measured or targeted by current clinically available tools. Addressing these underpinnings may be key to preventing or treating cerebral edema and improving outcome after severe TBI. Recent Findings This review begins by outlining basic principles underlying the relationship between edema and ICP including the Monro-Kellie doctrine and concepts of intracranial compliance/elastance. There is a subsequent brief discussion of current guidelines for ICP monitoring/management. We then focus most of the review on an evolving precision medicine approach towards cerebral edema and intracranial hypertension after TBI. Personalization of invasive neuromonitoring parameters including ICP waveform analysis, pulse amplitude, pressure reactivity, and longitudinal trajectories are presented. This is followed by a discussion of cerebral edema subtypes (continuum of ionic/cytotoxic/vasogenic edema and progressive secondary hemorrhage). Mechanisms of potential molecular contributors to cerebral edema after TBI are reviewed. For each target, we present findings from preclinical models, and evaluate their clinical utility as biomarkers and therapeutic targets for cerebral edema reduction. This selection represents promising candidates with evidence from different research groups, overlap/inter-relatedness with other pathways, and clinical/translational potential. Summary We outline an evolving precision medicine and translational approach towards cerebral edema and intracranial hypertension after severe TBI.

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Section: Cerebral Edema and Intracranial Pressurementioning

confidence: 99%

A Precision Medicine Approach to Cerebral Edema and Intracranial Hypertension after Severe Traumatic Brain Injury: Quo Vadis?

Jha

Kochanek

2018

Curr Neurol Neurosci Rep

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“…In the United States, a half-million cardiac arrests annually originate either in the hospital (for example, in patients who are undergoing care for general medical or surgical conditions) 1 or out of the hospital (for example, at home or in public venues, who are then brought to the emergency department) 2 . In both scenarios, patient outcomes are significantly improved when active temperature management is administered 3 and targeted temperature management (TTM) has been a standard of care for cardiac arrest since 2005. Over 5 million patients are admitted to intensive care units annually in the U.S 4 .…”

Section: Introductionmentioning

confidence: 99%

Esophageal Heat Transfer for Patient Temperature Control and Targeted Temperature Management

Naiman

Gray²,

Haymore

et al. 2017

JoVE

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Controlling patient temperature is important for a wide variety of clinical conditions. Cooling to normal or below normal body temperature is often performed for neuroprotection after ischemic insult (e.g. hemorrhagic stroke, subarachnoid hemorrhage, cardiac arrest, or other hypoxic injury). Cooling from febrile states treats fever and reduces the negative effects of hyperthermia on injured neurons. Patients are warmed in the operating room to prevent inadvertent perioperative hypothermia, which is known to cause increased blood loss, wound infections, and myocardial injury, while also prolonging recovery time. There are many reported approaches for temperature management, including improvised methods that repurpose standard supplies (e.g., ice, chilled saline, fans, blankets) but more sophisticated technologies designed for temperature management are typically more successful in delivering an optimized protocol. Over the last decade, advanced technologies have developed around two heat transfer methods: surface devices (water blankets, forced-air warmers) or intravascular devices (sterile catheters requiring vascular placement). Recently, a novel device became available that is placed in the esophagus, analogous to a standard orogastric tube, that provides efficient heat transfer through the patient's core. The device connects to existing heat exchange units to allow automatic patient temperature management via a servo mechanism, using patient temperature from standard temperature sensors (rectal, Foley, or other core temperature sensors) as the input variable. This approach eliminates vascular placement complications (deep venous thrombosis, central line associated bloodstream infection), reduces obstruction to patient access, and causes less shivering when compared to surface approaches. Published data have also shown a high degree of accuracy and maintenance of target temperature using the esophageal approach to temperature management. Therefore, the purpose of this method is to provide a low-risk alternative method for controlling patient temperature in critical care settings.

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“…After cardiac arrest in adults, a carefully conducted multi-center study initially suggested benefit from conventional levels of therapeutic hypothermia (3), while more recent studies have suggested that equal benefit might be produced by rigorous clamping of temperature in the patients at 36°C, a strategy often referred to as targeted temperature management (TTM) (4). Whether this approach simply prevents fever or represents a level of ultra-mild therapeutic hypothermia remains to be defined, and is a current area of investigation (5, 6). In children, the recent high quality multi-center therapeutic hypothermia after cardiac arrest trial, although negative for the primary outcome, produced strong trends toward improvements in neurological outcome and mortality despite being fairly underpowered (7).…”

mentioning

confidence: 99%

A “Metamorphosis” in Our Approach to Treatment Is Not Likely to Result From a Meta-Analysis of the Use of Therapeutic Hypothermia in Severe Traumatic Brain Injury*

Wallisch

Kochanek

2017

Critical Care Medicine

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The Brain and Hypothermia—From Aristotle to Targeted Temperature Management

Cited by 21 publications

References 57 publications

A Precision Medicine Approach to Cerebral Edema and Intracranial Hypertension after Severe Traumatic Brain Injury: Quo Vadis?

A Precision Medicine Approach to Cerebral Edema and Intracranial Hypertension after Severe Traumatic Brain Injury: Quo Vadis?

Esophageal Heat Transfer for Patient Temperature Control and Targeted Temperature Management

A “Metamorphosis” in Our Approach to Treatment Is Not Likely to Result From a Meta-Analysis of the Use of Therapeutic Hypothermia in Severe Traumatic Brain Injury*

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