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VOLUME 19 , ISSUE 9 ( 2015 ) > List of Articles


Targeted temperature management: Current evidence and practices in critical care

Sanjay Kumar, Jai Sharma, Ritika Dhurwe

Keywords : Critical care, post-cardiac arrest, targeted temperature management, therapeutic hypothermia

Citation Information : Kumar S, Sharma J, Dhurwe R. Targeted temperature management: Current evidence and practices in critical care. Indian J Crit Care Med 2015; 19 (9):537-546.

DOI: 10.4103/0972-5229.164806

License: CC BY-ND 3.0

Published Online: 01-09-2016

Copyright Statement:  Copyright © 2015; The Author(s).


Targeted temperature management (TTM) in today′s modern era, especially in intensive care units represents a promising multifaceted therapy for a variety of conditions. Though hypothermia is being used since Hippocratic era, the renewed interest of late has been since early 21 st century. There have been multiple advancements in this field and varieties of cooling devices are available at present. TTM requires careful titration of its depth, duration and rewarming as it is associated with side-effects. The purpose of this review is to find out the best evidence-based clinical practice criteria of therapeutic hypothermia in critical care settings. TTM is an unique therapeutic modality for salvaging neurological tissue viability in critically ill patients viz. Post-cardiac arrest, traumatic brain injury (TBI), meningitis, acute liver failure and stroke. TTM is standard of care in post-cardiac arrest situations; there has been a lot of controversy of late regarding temperature ranges to be used for the same. In patients with TBI, it reduces intracranial pressure, but has not shown any favorable neurologic outcome. Hypothermia is generally accepted treatment for hypoxic ischemic encephalopathy in newborns. The current available technology to induce and maintain hypothermia allows for precise temperature control. Future studies should focus on optimizing hypothermic treatment to full benefit of our patients and its application in other clinical scenarios.

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  1. Drabek T, Kochanek PM. Is hypothermia useful in managing critically Ill patients? Which ones? Under what conditions? Evidence Based Practice of Critical Care. I st ed. USA: Saunders, An Imprint of Elveiser; 2010. p. 437-44.
  2. Busto R, Dietrich WD, Globus MY, Ginsberg MD. Postischemic moderate hypothermia inhibits CA1 hippocampal ischemic neuronal injury. Neurosci Lett 1989;101:299-304.
  3. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-63.
  4. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549-56.
  5. Polderman KH, Herold I. Therapeutic hypothermia and controlled normothermia in the intensive care unit: Practical considerations, side effects, and cooling methods. Crit Care Med 2009;37:1101-20.
  6. Akata T, Setoguchi H, Shirozu K, Yoshino J. Reliability of temperatures measured at standard monitoring sites as an index of brain temperature during deep hypothermic cardiopulmonary bypass conducted for thoracic aortic reconstruction. J Thorac Cardiovasc Surg 2007;133:1559-65.
  7. Nunnally ME, Jaeschke R, Bellingan GJ, Lacroix J, Mourvillier B, Rodriguez-Vega GM, et al. Targeted temperature management in critical care: A report and recommendations from five professional societies. Crit Care Med 2011;39:1113-25.
  8. Polderman KH. Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med 2009;37:S186-202.
  9. Lewis ME, Al-Khalidi AH, Townend JN, Coote J, Bonser RS. The effects of hypothermia on human left ventricular contractile function during cardiac surgery. J Am Coll Cardiol 2002;39:102-8.
  10. Erecinska M, Thoresen M, Silver IA. Effects of hypothermia on energy metabolism in Mammalian central nervous system. J Cereb Blood Flow Metab 2003;23:513-30.
  11. Hägerdal M, Harp J, Nilsson L, Siesjö BK. The effect of induced hypothermia upon oxygen consumption in the rat brain. J Neurochem 1975;24:311-6.
  12. Palmer C, Vannucci RC, Christensen MA, Brucklacher RM. Regional cerebral blood flow and glucose utilization during hypothermia in newborn dogs. Anesthesiology 1989;71:730-7.
  13. Ehrlich MP, McCullough JN, Zhang N, Weisz DJ, Juvonen T, Bodian CA, et al. Effect of hypothermia on cerebral blood flow and metabolism in the pig. Ann Thorac Surg 2002;73:191-7.
  14. Aoki M, Nomura F, Stromski ME, Tsuji MK, Fackler JC, Hickey PR, et al. Effects of pH on brain energetics after hypothermic circulatory arrest. Ann Thorac Surg 1993;55:1093-103.
  15. Thoresen M, Whitelaw A. Cardiovascular changes during mild therapeutic hypothermia and rewarming in infants with hypoxic-ischemic encephalopathy. Pediatrics 2000;106:92-9.
  16. Reuler JB. Hypothermia: Pathophysiology, clinical settings, and management. Ann Intern Med 1978;89:519-27.
  17. Nesemann ME, Busch HM Jr, Gundersen AL, Gundersen AE, Newcomer KL. Asystolic cardiac arrest in hypothermia. Wis Med J 1983;82:19-20.
  18. Kirby CK, Jensen JM, Johnson J. Defibrillation of the ventricles under hypothermic conditions. AMA Arch Surg 1954;68:663-5.
  19. Martinez JB, Kass I, Hoffman MS. Factors involved in the recovery of a patient after prolonged ventricular fibrillation during hypothermia. J Thorac Surg 1958;36:749-56.
  20. Covino BG, Beavers WR. Changes in cardiac contractility during immersion hypothermia. Am J Physiol 1958;195:433-6.
  21. Covino BG, Hegnauer AH. Hypothermic ventricular fibrillation and its control. Surgery 1956;40:475-80.
  22. Polderman KH, Peerdeman SM, Girbes AR. Hypophosphatemia and hypomagnesemia induced by cooling in patients with severe head injury. J Neurosurg 2001;94:697-705.
  23. 23 Pozos RS, Danzl D, Human physiological responses to cold stress and hypothermia. In: Medical Aspects of Harsh Environments, Vol Textbooks of Military Medicine. Pandolf KB, Burr RE (Eds). Washington, DC: Borden Institute, Office of the Surgeon General, US Army Medical Department 2001 p. 351-82.
  24. Polderman KH, Tjong Tjin Joe R, Peerdeman SM, Vandertop WP, Girbes AR. Effects of therapeutic hypothermia on intracranial pressure and outcome in patients with severe head injury. Intensive Care Med 2002;28:1563-73.
  25. Polderman KH. Induced hypothermia and fever control for prevention and treatment of neurological injuries. Lancet 2008;371:1955-69.
  26. Luscombe M, Andrzejowski JC. Clinical applications of induced hypothermia. Contin Educ Anaesth Crit Care Pain 2006;6:23-7.
  27. Michelson AD, MacGregor H, Barnard MR, Kestin AS, Rohrer MJ, Valeri CR. Hypothermia-induced reversible platelet dysfunction. Thromb Haemost 1994;71:633-40.
  28. Watts DD, Trask A, Soeken K, Perdue P, Dols S, Kaufmann C. Hypothermic coagulopathy in trauma: Effect of varying levels of hypothermia on enzyme speed, platelet function, and fibrinolytic activity. J Trauma 1998;44:846-54.
  29. Valeri CR, MacGregor H, Cassidy G, Tinney R, Pompei F. Effects of temperature on bleeding time and clotting time in normal male and female volunteers. Crit Care Med 1995;23:698-704.
  30. Patt A, McCroskey BL, Moore EE. Hypothermia-induced coagulopathies in trauma. Surg Clin North Am 1988;68:775-85.
  31. Ferrara A, MacArthur JD, Wright HK, Modlin IM, McMillen MA. Hypothermia and acidosis worsen coagulopathy in the patient requiring massive transfusion. Am J Surg 1990;160:515-8.
  32. Reed RL 2 nd, Bracey AW Jr, Hudson JD, Miller TA, Fischer RP. Hypothermia and blood coagulation: Dissociation between enzyme activity and clotting factor levels. Circ Shock 1990;32:141-52.
  33. Valeri CR, Feingold H, Cassidy G, Ragno G, Khuri S, Altschule MD. Hypothermia-induced reversible platelet dysfunction. Ann Surg 1987;205:175-81.
  34. Arrich J, Holzer M, Havel C, Müllner M, Herkner H. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev 2012;9:CD004128.
  35. Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010;122:S345-421.
  36. Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010;81 Suppl 1:e93-174.
  37. Nielsen N, Friberg H, Gluud C, Herlitz J, Wetterslev J. Hypothermia after cardiac arrest should be further evaluated - a systematic review of randomised trials with meta-analysis and trial sequential analysis. Int J Cardiol 2011;151:333-41.
  38. Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med 2013;369:2197-206.
  39. Che D, Li L, Kopil CM, Liu Z, Guo W, Neumar RW. Impact of therapeutic hypothermia onset and duration on survival, neurologic function, and neurodegeneration after cardiac arrest. Crit Care Med 2011;39:1423-30.
  40. Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: A randomized clinical trial. JAMA 2014;311:45-52.
  41. Debaty G, Maignan M, Savary D, Koch FX, Ruckly S, Durand M, et al. Impact of intra-arrest therapeutic hypothermia in outcomes of prehospital cardiac arrest: A randomized controlled trial. Intensive Care Med 2014;40:1832-42.
  42. Saigal S, Sharma JP. Comment on Debaty et al.: Impact of intra-arrest therapeutic hypothermia in outcomes of prehospital cardiac arrest: A randomized controlled trial. Intensive Care Med 2015;41:171.
  43. Mikkelsen ME, Christie JD, Abella BS, Kerlin MP, Fuchs BD, Schweickert WD, et al. Use of therapeutic hypothermia after in-hospital cardiac arrest. Crit Care Med 2013;41:1385-95.
  44. Sinclair HL, Andrews PJ. Bench-to-bedside review: Hypothermia in traumatic brain injury. Crit Care 2010;14:204.
  45. Mourvillier B, Tubach F, Wolff M. Induced hypothermia in severe bacterial meningitis: A randomized clinical trial. J Am Med Assoc 2013;310:2174-83.
  46. Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev 2013;1:CD003311.
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