Transcript Video The Goldilocks Approach to Normothermia Management: Not too hot - Not too cold just right! Hello. My name is Rebecca Offner. I'm with B. D. Medical affairs. I'm here to introduce your speaker mary Kay Bader. She has been a nurse since 1978 with an emphasis on neuroscience Critical care nursing. She has been most honorably known as the first nurse ever to serve as the president chair of the neuro Critical Care Society. Mary Kay is currently employed as a neuroscience critical care nurse specialist at Mission Hospital. She is a sought after speaker on topics such as traumatic brain injury, spinal cord injury, increased intracranial pressure stroke, neuro interventional therapy, T. T. M. And aneurysms mary Kay is well published and you've probably been reading her work since nursing school. She has been the recipient of many a CN honors and I introduced to you your speaker for today mary Kay Bader greetings. This presentation is the Goldilocks approach to normal thermal management. Not too hot, not too cold. Just right. My email is on the screen Bader MK at AOL dot com and I'm happy to share any handouts or if you have any questions you'd like to reach out, please feel free to email me. I work at Mission Hospital in Mission Viejo California. We are a comprehensive stroke center, american college of Surgeons trauma center and we practice a lot of normal ther mia at our institution in the neuro population and in the post cardiac arrest population as a neuro critical care clinical nurse specialist. It is really important that when your team is managing patients with neuro diagnosis in the ICU or with patients who are post cardiac arrest that norma therm. Eah management be a key approach to how you manage all of your various populations, intertwining normal ther mia into your practice protocols, into your team management strategies, into your multidisciplinary rounds when you're rounding is really important to hardwire the concept within your ICU practitioner group. My disclosures are listed on this slide. The objectives for this presentation are to relate the path of path of physiological impact of injury to the central nervous system, to temperature management, to identify some key physiological and systemic effects of temperature on the ICU patient. To translate research on normal ther mia to practice by developing evidence based protocols and to apply a normal thermal protocol interventions to an actual case study. Temperature is a vital sign and temperature is a very important vital sign because temperature impacts various systems in our body. When someone's temperature increases, the heart rate increases, which increases cerebral blood flow to the brain, this causes an increase in intracranial pressure, especially in patients who have some form of pathology, whether it be cerebral oedema from a cardiac arrest or some type of injury, like an epidural or subdural hematoma, cerebral contusions, inter cerebral hemorrhage stroke. Any one of these populations will have a change the dynamics inside their premium so that an increase in cerebral blood flow can negatively impact them. It also causes the respiratory rate to go up. If you've ever assessed your patient at eight in the morning and they can respond to you and answer questions and then have that same patient develop a fever of 100 and one or 39 C. Suddenly that patient who is answering questions before is not so awake is confused and may not be able to follow commands so it does affect cognition. Now the pressure we see a decrease in blood pressure, especially in people with sepsis or septic shock. P. B. T. 02 This is a way to measure oxygen in the brain is not adversely affect by the rise in the temperature, but rather by the body's response, which is generally shivering when you go to intervene and then shivering will cause it to decrease. So temperature has a profound impact and understanding why it's important to manage temperature and to prioritize it in your interventions is very, very important. Let's take a look at the injured brain. There are many ways that the brain is injured. Local or global ischemia situations that create increased intracranial pressure stroke, hemorrhage, traumatic brain injury. When we have somebody with focal ischemia, for instance, in ischemic stroke, perhaps the middle cerebral artery has concluded. When that happens, there's no blood flow to a section of the brain and it undergoes chemical changes, creating significant injury to the tissue. So there's an ischemic zone and the brain can react if blood flow is not reestablished. With cerebral oedema. Now the innermost part of the core of that stroke area will die within 30-60 minutes. If re profusion is not reestablished, there's the greater penumbra area which can affect a lot of the hemisphere that when re profusion occurs, still has areas of potential damage from the cellular changes that occur. Global ischemia is generally associated with a cardiac arrest where their cessation of blood flow. It can be transient. It could be for a prolonged period of time whether or not someone receives cardiopulmonary resuscitation, which means we're trying to preserve blood flow to the brain during that arrest period. All impact the degree of ischemia that occurs inside the cranial vault. When the brain has suffered a scheme media and anoxia, it is more vulnerable to the impact of temperature and the impact of temperature. Especially fever in these patients will cause cellular derangement cell damage and potentially eight cell death brain injury. When we look at trauma. When we look at patients with stroke, we know that fever after trauma or ischemia exacerbates the damage from the original insult and it worsens clinical outcomes. There is a significant increase in the metabolism of the brain. The brain can consume 6-13% more oxygen in the presence of fever. As that heart rate has increased as blood flow increases, hypothermia worsen cerebral oedema and its associated with increased intracranial pressure and if vulnerable, the patients are at greater risk for seizures. We know from the literature that there are recommendations on avoidance of fever, especially in the post cardiac arrest population. The 2020 American Heart Association guidelines that were published late last year statement in it that's his fever after the return of spontaneous circulation is associated with poor neurological outcomes. In patients not treated with T. T. M. Although this finding is reported less consistently in patients treated with T. T. M. It is not established whether treatment of fever is associated with an improvement in outcome. But a treatment or prevention of fever appears to be a reasonable approach. There are numerous studies that have looked at patients who have undergone T. T. M. And then had a fever as they returned into that normal therm eah phase. This was a paper that was published in your a critical care that evaluated the Association of Fever after the first days of ice you state and neurological outcome in post cardiac arrest patients. It was a retrospective study of 132 patients. Fever was present in almost 80% of those patients and that was associated with patients who were of older age who had non shock kable rhythm, so that fever was more prevalent. Higher simplified acute physiology, physiology, score papillary abnormalities, the elevated degree of maximum body temp cord during the ice you stay. So the longer they had fever and the more the farther out from their insult seemed to worsen their outcome. There was significant interaction between T. Max and when the temperature occurred and how far out. So the later the T. Max occurs, the more deleterious the effect was observed on outcome. And this chart reflects that presence in showing you the the increase in temperature to 39 to 40 to 41 degrees and uh the days out where this temperature has occurred. So time of T max. So the longer the patients in fever and then the longer the days that they go out and hire the fever was associated with a poor outcome. There are studies that published that look at outcomes in stroke in trauma. This is a quote from David Greer's paper that was published in stroke in 2008, fever was consistently associated with damaging effects. Whether the neurological injury was a schematic hemorrhagic or traumatic and origin and whether the outcome being measured was clinical, functional or economic. Numerous papers published have suggested that elevated body temperature has now been associated with worse outcome. So a longer length of stay, more adverse outcomes in the neurological relation. Mike Derringer published an article back, Gosh 17 years ago from Barnes, Jewish Hospital and they looked at over 4000 patients that were in their neuro icu fever was significantly associated with a longer ICU length of state and worse clinical outcomes. David Greer's paper, which was a meta analysis of over 14,000 patients again found that fever was significantly associated with worse outcomes. An interesting paper that came out of Columbia back in 2007 by Fernandez at all, took a look at the fever burden in patients with subarachnoid hemorrhage and more importantly, they looked at the fever burden in association with the hunting has score, which is a clinical scoring. To look at how the subarachnoid hemorrhage has impacted the individuals who are hunting has one is someone who's awake, who has maybe slight fever or slight headache versus somebody who is a hunting has five, which is somebody who is more abundant who is unconscious, who is in coma, who's got scope, coma score is probably about three or four these. So the higher the score, the worst clinical grade in the hunt and has scoring. And you can look at the slide on the left of the picture, on the left hand side and you look at this is the daily maximum temperature above 37 degrees. Based on a hunting has won in two, which is the lower graph versus the higher graph which is hunting has 3 to 5. So you can see that the fever burden is significant in patients with a higher hunt and has 34 and five. And so the modified ranking scores associated with the modified ranking, patients with a hunting has these are three month modified ranking scores. But looking at fever burden again. So the modified ranking, if the individual had up to one degree fever burden, They're modified Rankin was 0-3, which is more favourable than someone who had a significant fever burden up to 1.8°. And they're modified. Rankin was uh 4-6. So I'm going to ask you, what's your institution's definition of fever. When do you start interventions According to Dr. Stephan Mayer fever is defined as a temperature greater than 38°C. And when we look at the impact of fever on the physiologic system, it's significant. We know that when fever is part of an infection that it's an adaptive response by the body to fight that infection and it's generally seen as protective and not routinely deleterious. However, the adverse effects of hypothermia and patients with brain injury are significant. Regardless of the source of the fever, fever propagates secondary injury. Now, there are many sources of fever. If you look at infectious sources pneumonia, urinary track infections. Central line infections, uh noninfectious causes. A fever include medications but there's also neurogenesis or central fever which is fever that is from the damage to the thermo regulatory center. Or in patients who have a lot of blood in their head. From, let's say, an epidural or subdural hematoma and inter cerebral hemorrhage. That just the presence of blood subarachnoid hemorrhage um increases the temperature load in those individuals that feed the brain reacts with an increase in temperature. Studies have shown that 20-50% of your a critical care patients have a fever and that fever after trauma ischemia exacerbates the damage from that original insult and can worsen clinical outcomes. So what is your goal for managing temperature? And it depends on what your goal is, where you want to keep your patient's temperature under. But more importantly, how are you measuring your temperature? Where are you measuring your temperature? We know that the brain is the hottest organ of the body. And when you look at the brain temperature and compare that to a quarter temperature such as a pulmonary artery temperature or softened jail temperature or perhaps a bladder fully temperature that are all considered core temperatures. That the brain is about two degrees hotter, up too. Could be a degree to two degrees. So making sure that you accurately measure temperature is important. So I'd ask, where are you measuring your patient's temperature and are you doing it continuously or intermittently? This was a chart put together by Nancy Monroe, whose acute care nurse practitioner working at the NIH when this publication was put out in 2014. And it's a great chart that looks at different sources of measuring temperature. So the pulmonary arteries considered the criterion core temperature. That is the standard when you look at s a fragile and bladder. Those are also considered core temperatures. And they're off from the criteria by 0.1 and 0.2 degrees. The temporal artery is a core temperature, but it really depends on technique, on user technique. So, if you're not measuring appropriately, it may not be that accurate. Recto. Oral temperatures are considered peripheral temperatures. Rectal temperatures about .3° off from the criterion. But depending on where the catheter or the little um rectal probe is, it can be influenced by the presence of stool. Sometimes it can fall out of the cavity and then you're no longer measuring the temperature accurately. Oral temperature requires again, correct placement uh in the sublingual pocket just to make sure that you have in the right location and away from the endotracheal tube and then the axillary temperature is a peripheral temperature. And here's my advice. Just don't do it. Just don't do it in a critical care setting. In an ICU setting. You should not be measuring a patient's temperature via the axillary method. It is not accurate and I would caution you from using that modality when we look at what the recommendations are in the literature for measuring temperature. This is a recommendation that was part of the neural critical care society implementation of targeted temperature management evidence based guidelines. This guidelines was led by Dr Lori Madden, a PhD nurse and Dr Neeraj padilla, a neuro intensive Isse added the university of Maryland. Um and they were joined by other colleagues. But in those recommendations they suggest an esophageal temperature probe during all phases of T. T. M. And if an esophageal probe is not appropriate available, we suggest using a bladder temperature probe and that temperatures clinicians should monitor the temperature continuously. There are studies that have taken a look at the difference in measuring temperature in different sites. Laura McEvoy document prepared nurse published an article in Journal of neuroscience Nursing in 2000 and seven looking at 31 patients where they compared pulmonary artery temperatures too, a brain temperature and found the brain temperature to be hired. We did a study at our center looking at brain versus bladder and found that swivel temperatures tended to be 1.3° higher than bladder temperatures. The neural critical care society had another set of guidelines published in 2014 called the multi modality monitoring guidelines. That was led by Dr Peter Larue. And in those guidelines they recommend monitoring core body temperature as a surrogate of brain temperature unless brain temperature is available. And in those same guidelines, they recommend a continuous monitoring temperature while the patients in the ICU, especially during the hyper acute phase. Now, once we have our temperature measured, what are the triggers for treatment? Well, it depends on what literature you're reading common definitions of fever, described fever as greater than 38.2° and that the treatment should be instituted after that temperature is reached. The American Heart Association stroke Association guidelines talk about in a ski mix joke 38 degrees and an inter cerebral hemorrhage and subarachnoid hemorrhage. Treatment of fever is reasonable, but they don't give a cut off range In cardiac arrest. We know that poor outcomes are associated with temperatures greater than 38.5 and in traumatic brain injury. The brain trauma foundation does not have any recommendations on temperature, but the american College of surgeons to quit guidelines do recommend um, somewhere between 36 38 degrees to have the patient there and then if it's above 38 to treat the patients. Well, when were we have a patient in our icu and the temperature starts to escalate and we start to give treatment. You've been in this situation where the temperature is 38°, the metabolic demand is increased on your patient and you've called the room. You've taken off the blankets. You've maybe put ice bags on the patient. Maybe you've tried some acetaminophen and then temperature continues to escalate and sometimes it can escalate rapidly So it can go up 2-3° over the course of an hour. And what we know from refractory uncontrolled hypothermia is that the patient is going to sustain neurologic damage and they're kind of worse outcomes if that temperature is left unchecked. And our goal is to bring that patient's temperature down. So is it better to do control normal thermal to, for instance, in my ICU, we will put a fully temp probe in in the critical patients who are on ventilators and we'll monitor their patients continuously and as soon as their temperatures hitting 37.5, we're starting the acetaminophen. We're starting cooling strategies. But if it hits going up to 38 degrees and we've not been successful, we will put on our device and we will do controlled normal hermia, meaning we will keep that patient's temperature at 37 degrees. And so it is not uncommon, especially in aneurysms, subarachnoid hemorrhage patients to have controlled normal thermal as long as they are critically ill or in the traumatic brain injury population, in the spinal cord population, any of those stroke population, we will do enforce normal thermal to, especially after they've spiked the first time. Now, fever management practices of nurses is fascinating. It's a fascinating subject. There are a couple of studies have been published over the years. The first one in 2007 out of the University of Washington Where it was a survey of fever management practices of 2007, was by Thompson, Kirk Nous Mitchell and Webb. In the 2015 repeat study was by rocket, Thompson and Blissett. There was a quote in the 2007 article that I it is so true and I love this quote as the provider of direct patient care. The bedside nurse is the primary decision maker regarding anti pirate IQ medications regardless of weather and evidence based protocol exists in a clinical setting. So basically it's up to us as nurses, as those providers to monitor temperature and to get treatment started early rather than later. Now in the 2007 Uh survey, they did the 15 item questionnaire, they had 328 responded, 68% were from academic centers and only 19% of the practicing nurses who responded to that survey had an active hypothermia or fever Pro protocol in place in there, I see you or on their Euro unit. The trigger for initiating that protocol ranged anywhere from just over 37° to 40°. Can you imagine waiting to 40° to start cooling somebody I can't. The mean temperature where they would initiate cooling was 38.2. And their primary treatment modalities were acetaminophen, ice packs, water cooling blankets and tepid bathing. Now that survey was repeated in 2015, they also wanted to look at some characteristics that influence nursing selection of the treatment of fever. They had 291 respondents. They adapted that 15 question uh item questionnaire from 2007 to use. And then um They found that the use of a treatment protocol had increased to 26%, but that was still only one in four of the nurses who responded. Now, what was fascinating is that they look, they asked some questions were the neuro populations included in the protocols. Well, if you had a protocol, it included all neuro patients in 43% of the survey responders. If the individual disease specific protocol was written, Okay, most likely to have a specific treatment protocol And they found it was more prevalent in the hospitals, from responders from hospitals in the Western United States vs the Midwest, which had the lowest standardized treatment. So 35 of the Western U. S. Hospitals had some sort of treatment protocol for fever management, whereas only 20% in the midwest, The target for when treatment was initiated, the mean temperature was 38.4 interesting. If you were a certified nurse a C. N. R. N, you started your treatment at 37.9, which I think reflects. There's respondents included progressive care units and neuro units versus if you were C C. R. N. So this is more representative of critical care, the target temperature. To start treatment with 37.6 Nurses based their decision on physician orders, 38.2 or national guidelines 37.7. And treatment was similar in to the interventions. Now, another paper that was published I came across I found was also enlightening was that they were themes that emerged from the early 2007 paper. And so Thompson correctness and Pam Mitchell published another article to go along with the 2007 survey and they found that there were three key things that influence fever management practices the nurse, the patient and barriers. The nurse attitude is important. Fever is good or fever is bad. In my icy fever is bad and I lecture the new nurses when they come in in their Euro one oh one course. They have a normal for MIA lecture for 30 minutes. And so they leave that lecture knowing that fever is not acceptable in our neuro critically ill population, in the independent nursing judgment, the degree to independent judgment, or is it very restrictive and the lack of knowledge or desire for evidence based protocols. When we look at the patient, fever is an integral part of nursing care and we have to individualize that care to our patients. Managing fever is hard. It's hard work. There's no getting around it. It's difficult. I'm not gonna paint a rosy picture. It can be challenging and you may need more aggressive strategies than simply acetaminophen. And a cool back Now barriers hospital policies that would dictate. You don't treat fever unless it's over 39, which I would find entirely unacceptable. Uh they're forbidden to use more expensive technologies. There are hospitals in this country that will forbidden nurse from using some sort of technology because it costs money, no protocol or inability to get everyone on board. And physician disagreement not uncommon to have a disagreement between trauma or critical care and neurosurgery on the importance of fever management. So they did offer some solutions um in the article by Thompson correctness and Mitchell. They said the organizational culture must empower nurses to implement change in their institutions and we have to promote a patient centered approach and a learning environment. We need to use and implement nurse led evidence based protocols and communication or the lack thereof of independent and collaborative nursing action. You need that communication and you need that interdisciplinary collaboration so that your practitioners can come together, look at the evidence and right and develop their protocols and implemented. So hopefully when you're looking at goals and the clinical considerations for maintaining normal ther mia, we know that when we're doing normal thermal, we want to do the least invasive because we want to be able to maintain their clinical exam. We know that when we try to alter temperature that we get vessel constriction and shivering that will attempt and that sedation agents when used to counter the shivering can impact level of consciousness and that can get a little tricky. So when we think about normal thermal management, we need to think about things like, well how does the body react to temperatures? What are the strategies we can do to reduce it? And how can I put that together into a protocol to actually use it at the bedside? So, thermal regulation, it's all about the hypothalamus, right? That is the network where there is temperature sensitive neurons temperature insensitive effect of neurons and depending on the body temperature, the hypothalamus acts to bring us into balance. It wants to maintain homeostasis. So as temperature increases the thermal receptors in our hypothalamus, they sense that temperature increased. They start the firing of the warm sensitive neurons which says viso dilates sweat, increased blood flow. Try to lose that temperature right? Bring that temperature down the same side. If we are too cold the cold sensitive neurons fiber and then we Veysel constrict and start to shiver. And when we start to shiver we generate hit where to warm the body back up. So there are involuntary sympathetic responses that these are constriction, that pilo erection. The the increase in shivering are all the result of trying to warm up the patient. Right? That's what the body, the body is trying to warm themselves up. It doesn't like this cool blanket or cool wrap or cool catheter or whatever you have in the patient. It doesn't like to be told you need to cool down or warm up and so it starts to react by doing these things to generate heat. But in the process, it also increases the metabolism of the body, increases oxygen consumption. We all have a threshold for thermo regulatory response in. It's an elevated set point and that set point can shift depending on where the body temperature is and how it's moving shivering as part of trying the body, trying to counter what you're doing, let's say, the temperatures up and you're trying to bring the temperature down. So you have now applied some cooling strategies and the patient's shivering. Well, there's the good, the bad and the ugly of shivering. There have been studies that have suggested that the good side of shivering is that it reflects the degree of brain damage and that if you have shivering for instance and cardiac arrest survivors undergoing T. Tm. That that's actually a good prognostic sign. So that's the good side. The bad is that there is an increased consumption of oxygen in the body. There is our body is reacting. There's counter cooling or warming techniques that are going and studies have looked at the increase in calorie consumption can consume almost 3600 calories if somebody's in full body rigors vs 1300 calories if you're at a resting state. Uh There are studies that have looked at the brain tissue, oxygen and the brain tissue oxygen levels fall when the patients begin to shiver. This is one of our patients where we were maintaining the patient at 37 degrees. And you can see that the there's temperature mean blood pressure I. C. P. P. B. T. 02 and cerebral blood flow. And every time the patient started to shiver we started to see a drop in the blood flow in a drop in oxygen would give them a medication. They'd stopped shivering, it go back up, they'd start shivering again. Then then the oxygen would go down and the blood flow would go down. It was fascinating to watch. Now there are ways to monitor for shivering subjectively. Look for the goose bumps on somebody. But there's also the bedside shivering assessment score. It's pretty much of a universal score that most people use 0 to 3 quantifying the amount of shivering. And there are also tools like E. G. Derived technologies that look at E. M. G. And E. G. And can reflect the shivering, that motor activity in that particular device. Uh in the targeted temperature management guidelines, they do recommend the bedside shivering assessment score because of its established accuracy and inter rater reliability. Uh The B. S. A. S zero is no shivering, one is mild shivering to the neck and the chest region the mandible region A two is shivering that's now spread across the upper extremities and three is an all four extremities and the patients practically coming off the bed. Now this is a patient from our site here where we were doing temperature interventions on a cardiac arrest patient. And um you can see the picture on the top as a biz of 75 but notice next to that 75 is a yellow filled square which is measuring 80 mg. And what happened is that we are assessing the patient when we see the presence of a lot of E. M. G. Activity. We know there's a lot of micro shivering going on and that has caused this by spectral index number to increase. Because that biz number is a mathematical calculation of E. G. And e M. G. Now we gave the patient was already sedated. Um They had a bear hugger on them, uh We bolas them with north huron and you can see that the MG boxes now empty and the actual number of the biz at 33 is a true reflection of sedation. So when you see that yellow box, if you have a methodology that can look at E. M. G. That is very helpful to quantify, especially in micro shivering. Other ways that you can look, if you start to see the water temperature, take a dive on your machine that you're using to cool somebody down or warm somebody up. You will see the water temperature dipped down to like the 5 to 13 degree range. And you can then assess the patient to look, is it possible that there shivering? So you see uh instead of warming like they're supposed to, they suddenly have a dive in their water temperature. So this is another way to look at that water temperature where water temperatures in blue and you can see about halfway through the screen, where the water temperature comes down to about 20-25° and the patient's temperature is actually escalating more than it should. The green box that you see. The green line is representing what the targeted temperature should be as your rewarming this patient. But we have where the water temperature went down, we see the patient's temperature go up so the patient needed to have their shivering addressed so helpful. Hence, look at your water and patient temperature trend indicators. Look for drops in the water temperature of your device that you're using. That you can see it's the machine is working harder um To counter what's going on. Always make sure that your probe is correctly placing that there's good measurement with that particular probe and check for micro shivering as well as visible shivering. Now when patients have a fever, treating fever is hard. You need that's the patient's temperature. Um I prefer continuously. But every hour if they're in the critical care unit and you've noted that the temperature has been escalated or perhaps according to your hospital protocol I always worry about places that monitor temperature every four hours. Because what do we look at? Like heart rate every four hours? And then I see you know we watch it continuously. If it's a vital sign why aren't we watching it continuously? Watching pulse ox continuously. You're watching the respiratory rate continuously. The E. K. G repeat sakes. Why are we looking at the temperature? So when fever does occur you need to do your neuro exam. You need to start to intervene to bring that fever down. Um You're gonna need to be prepared for anti shivering interventions. So having some type of treatment protocol and in order set that's there that allow you to then go to the physician or the provider and say I need the normal thermal to order set which gives you the ability to treat temperature but also the ability to treat shivering so hard wiring T. T. M. For fever reduction includes the team the guidelines and the protocols and all those can influence the outcomes. We have a normal ther mia protocol for our critical neuro and post hypothermia patients. And it outlines how we manage patients in our ice use. If their temperature is too low, there's temperatures too high. Um And we want to bring it in just right. And so these guidelines speak to how we assess the patient's of having a reliable temperature probe in the patient. We want to assure that it's either measured continuously or every 1-2 hours. Now, if the temperature of the patient is less than 36 or above 38, you might want to do it more frequently with reassessment in 15-30 minutes until you're within the right range, within a degree of normal temperature On the floor. We're monitoring temperature every 4-12 hours. Now if you're patient comes into cold and this can happen, we have patients that arrive out of the operating room or out of the interventional suite and their temperature is 34°. So you have to safely bring that patient's temperature back up to the normal thermal arrange. So you might want to start with warm blankets, forced warm air systems that can blow hot air on the patient. And if the temperature is refractory to these modalities, Then applying some type of device may help you to safely rewarm that patient back up to 37°. It is important that if the temperature is let's say 34° or less, that you also monitor your fluid and electrolyte levels. So you're going to look at your bmp, um you're gonna get your magnesium levels because when patients rewarm they can have shifting of their electrolytes and potassium levels can go high calcium phosphorus. Um You want your mag level to be above normal to counter shivering. So you want to reassess the patient's temperature closely during this time of rewarming. Now let's say that the temperatures over 38°. So now we're not cold but the patient's hot. So we want to administer acetaminophen. Uh and if you can get ideas acetaminophen, you're better off than a lot of us who now we're finding pharmacies and hospitals restricting the use of ideas cinnamon if in. Uh so then your other routes, they're done N G R O G tube or rectally monitor temperature response to a decrease or increase in temperature And have some type of escalation. So you're going to put ice bags on the page, you're going to cool the room down. Um we also have a strategy where we use ice sailing Boulis is and this is 20 ml per kilo of ice saline, given over 30-45 minutes through a peripheral line. Now, in order for nurses to do this, we have to have a consistent temperature monitoring device in the patient. We have to call the physician and review the intake and the output. They're not too violent loaded. So, by giving this patient to leaders of ice and you know, we could put them into heart failure. So we want to make sure that it's safe to give the fluids. The physician or provider may order some Lasix after the administration of ice, saying that especially if they're concerned about fluid overload, you need to observe for arrhythmias while you're giving the ice selene and it has been successful if you're given it fast enough, I think that's the air that a lot of people make is that it takes them an hour and a half to give it, you have to give it in 30 to 45 minutes to that peripheral line. Uh and uh an individual can't have more than two ice alien challenges in 24 hours. Now let's say that the temperature still doesn't go down, still doesn't go down. So then you're going to get into some advanced methodologies, whether it's noninvasive core cooling or intravascular cooling or soft gel cooling. Um Some places in the world have nasal cooling methodology. So whatever the methodology is, you may need to put in that into place if you can't get the temperature down. Now in the targeted temperature management guidelines from N. C. S. It says which method of T. T. M. Causes the least temperature variability to maintain a constant patient temperature. We recommended using intravascular catheters or gel pads if such catheters are not available. And to minimize temperature variability is in neonatal so unlikely that this audience is using neo neyts. They suggest a servo controlled body wrap over conventional methods. To minimize overshoot, we recommend gel pads over conventional methods and again in the neonatal population. To minimize overshoot, we suggest using temperature modulating device with servo controls and gradient temperature changes. There are evidence of advanced cooling methods that have been very successful in clinical practice. This is an early paper by Dr Stephan Mayer and his group when he was at Columbia, which showed the high presence of fever in the neuro ICU population, And that they found that using an advanced cooling method, they were able to reduce fever burdened by 75% vs traditional water circulating blankets. An article published in 2016 bio Djula saw 70% of patients treated with advanced cooling methods reach targeted temperatures in under two hours and that traditional water circulating blankets required 16 hours to reach target temperature. That's a lot of brain damage going on with uncontrolled temperature, 81.8% of patients treated with traditional water circuiting blankets experienced rebound hypothermia. So keeping an eye on the temperature that close temperature monitoring is important. So I already talked about the good, the bad and the ugliest shivering management. But how do you go about countering shivering? Well, the easiest least invasive method is counter warning. It's very helpful if you've ever been in a cold environment and you get in your car and you're shivering and your heater starts in your car and you put your hands up to the heater and you warm your hands up and suddenly you stop shivering. So that warm air flowing over the receptors sometimes can really fool the body sedation prevents if, when you sedation to counter shivering, uh that will reduce the metabolism lobe, but it also is going to alter your clinical exam. So counter warming as a first option is a great intervention. We'll have our cooling device on and then we'll have a warm air circulating blanket blowing hot air over their arms and their legs and their body countering the shivering. So we have two devices on the patient once cooling ones being used for treating shivering in the guidelines from T. T. M. They did ask, ask the question. Just treatment of shivering result in similar functional outcomes as compared to know shivering. And it's a stated clinicians should treat shivering promptly and they recommend a stepwise approach to shivering management. So in your a critically ill patients undergoing T. T. M. Is metabolic demand similar to patients not undergoing T. T. M. And it says clinicians should be aware of the impact that T. T. M. May have on metabolism and substrate utilization. And so keeping in mind treating shivering is important. I'm going to show you a couple of different ideas for shivering management come from a couple different sources. This one's out of the journal of intensive care, published in 2016. Again, a a stepwise approach very similar to our protocol that we use at mission hospital, where we start with acetaminophen skin kind of warming. The physician provider will start views far around the clock, which helps potentially eight map Erdene will give mag sulfate Pulis's and raise the magnesium levels. Um if they continue to shiver them, a paradigm decks minatom in it and fentaNYL or effective. And then if the patients not intubated and they need more aggressive strategies like propofol and a paralytic, then you're going to need to intubate the patient. This was an article published in the Journal of neuroscience Nursing in 2000 and 18, which shows again a stepwise approach. This is from the university of Maryland. And so once you see the same interventions, it's just listed in a different way with a step B. S. A. S of zero acetaminophen boost bar mag skin counter warming when shivering is localized to the next month or X men perdon decks minatom Uddin fentaNYL and then as it continues to spread, getting more and more aggressively sedation management decks minatom Uddin an opiate propofol and last the paralytic. Well to bring this up into a conclusion, I'd like to share with you a case study where managing temperature was actually very helpful in the management of intracranial pressure. This was a 14 year old male who was crossing the street following a football game when he was struck by an suv going 40 miles an hour. 911 was called paramedics arrived at 21 45. The Glasgow coma score was seven. The blood pressure was 90 bell pie patient heart rate. 100 reps with 32. His color was white, his skin was cold. He had a deformity to the right lower leg. He was put on a backboard in a c collar, designated a critical trauma. And arrived at our center at 21 58. He was emergent Lee intubated in the trauma room with a 7.5 et tube vital signs showed hemorrhagic shock. His blood pressure was 58 by Palpitation. Heart rate was 100. His IV's were started connected to a rapid infuser and a massive transfusion protocol was initiated. The trauma surgeon noted a large 15 to 20 centimeter laceration on the neck with large amounts of blood coming from under the collar. He could see the sternum Skydome, asteroid muscle and the clavicle ahead. The area was packed, pressure was applied and it was noted that he did not have distal pulses. His neuro status was a GCS of seven. He also had an open compound fracture of the nose and extensive laceration to the face. His chest was normal, his abdomen was normal. His pelvis was intact indiana complicated fracture to the right lower leg. Ct scan done at 22 20 showed by frontal contusions with perry focal oedema and a small contusion. This is a C. C. T. Scan showing up on the upper picture on the right hand side, a cerebral contusion that is just starting to blossom in the inferior frontal lobes. But overall the brain is said to be very tight and had significant cerebral oedema. He went straight to the operating room where they found a left facial vein torn off the internal jugular vein. So they fixed that repaired the stern of Clyde. Domestic mastered muscle and the nasal fracture splinted the lower leg. Uh In all, he had 10 units of packed red blood cells, four units F. F. P, 10 units of platelets and 10 units of cryo. A repeat ct scan shows immediately after the operating room. We saw some extension of those contusions now in both frontal lobes. Uh He arrived in the pick you and was very agitated. He excavated himself, required emergent re intubation. His vital signs were stabilized. We used the pupil diameter device which is a handheld device that quantifies pupil reactivity and it showed um slow reaction to the pupils at 0.6 millimeters per second, indicative of increasing intracranial pressure. So he was taken to back to the operating room for placement of intracranial pressure monitor and brain tissue oxygen monitors. He also had a cerebral blood flow catheter place. Now this has given you a snapshot of some of his vital signs. Here we see the C. 02 P. A. C. 02 or entitled Co two is 42. Map is 86. The I. C. P. Is 23. The CPP is 63 the P. B. T. 02 is 20 and the temperature is 37.4. So they were doing interventions to bring the down but the again climbs up to 26. His CPP's down a little bit so his temperature jumped up to 38.5. And we think that it did adversely affected the intracranial pressure. So we did cooling measures and we're able to bring his I. C. P. Down to 15 in a CPP settles down on the next day we see the I. C. P. Spikes up to 28. When the temperature increases to 38.5. He was given hyper tonic saline for his I. C. P. And he was also um we applied a cooling device to aggressively bring the temperature down to 37 degrees. Now during the night shift he did stabilize his ICP was 15-20. We had controlled normal thermal going on PB. Co. two is in the 40s which was normal. Now. Here you can see the I. c. p. increases up into the 20s. His temperature was controlled. But what had happened is he developed compartment syndrome in his leg and that did adversely affect the rest of his body especially his brain. So he was put down the compartment syndrome was addressed and we started a pentobarbital coma protocol to reduce his intracranial pressure. And we had enforced normal hermia occurring. So uh day three I. C. P. Was controlled on Penta barb temperatures within normal limits. Um And by day four we had a little bit of bump in the road. They had taken off the cooling device and the temperature escalated back up. And we saw a reflexive increase in the intracranial pressure so that we we instituted cooling measures again and the I. C. P. Settled down. This was his C. T. Scan. On day five. You can see the brain is uh much better the left side of the brain. You can see there's not really visible ventricle but the patients I. C. P. Was more manageable. We're able to wean the barbs. On day 12. Day 14 he underwent close reduction in external fixation of the right tib fib fracture. His intracranial pressure monitor and oxygen catheters were removed on day 16 he was excavated on day 18 he went to rehab on day 28 and he was discharged home working on Algebra and other studies on day 54. And he went back to school for his spring semester of his freshman year. Well, I hope in this last hour, I've been able to identify the key concepts surrounding targeted temperature management and how important it is to keep the patient's temperature controlled to minimize that neuro injury that's occurring normal. Hermia is an important strategy to limit damage and assessing the patient frequently for temperature as well as for shivering when you're doing temperature. Lowering modalities is important. So identify and treat shivering as early as possible. These are the references that I would refer you to and I want to thank you for your attention. Created by
