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![BTF [3rd Edition]
Recommendations on TTM
• BTF – Level III (Optional)
• Cautious use of hypothermia for adults
• Not recommended for children
• Local cooling of the brain and combination of
hypothermia with drugs should be evaluated
3rd NSI Super Specialty CME on
NeuroTrauma, Udaipur
July 2018 BTF, 2007
Targeted Temperature Management in TBI](https://image.slidesharecdn.com/targetedtemperaturemanagementintbi-190921163622/75/Targeted-temperature-management-in-traumatic-brain-injury-11-2048.jpg)
![BTF [4th Edition]
Recommendations on TTM
• Level I and II A
• There was insufficient evidence to support a Level I
or II A recommendation for this topic.
• Level II B
• Early (within 2.5 hours), short-term (48 hours post-
injury) prophylactic hypothermia is not
recommended to improve outcomes in patients
with diffuse injury
3rd NSI Super Specialty CME on
NeuroTrauma, Udaipur
July 2018
Targeted Temperature Management in TBI
BTF. 2016.](https://image.slidesharecdn.com/targetedtemperaturemanagementintbi-190921163622/75/Targeted-temperature-management-in-traumatic-brain-injury-22-2048.jpg)
Uploaded byDhaval Shukla
Targeted temperature management in traumatic brain injury
The document summarizes research on targeted temperature management in severe traumatic brain injury. It discusses several key studies that have evaluated inducing hypothermia or maintaining normothermia/fever control in brain injury patients. The NABIS:H II and Eurotherm3235 trials found no clinical benefit to early, short-term hypothermia induction. The Brain-Hypothermia trial found no difference between prolonged mild hypothermia and fever control. Ongoing trials are further evaluating the potential roles of hypothermia and tight fever control. Current guidelines recommend maintaining normothermia and preventing fever after brain injury.
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Targeted temperature management in traumatic brain injury
- 1. Targeted Temperature Management inSevere Traumatic Brain Injury Dhaval Shukla Professor of Neurosurgery, NIMHANS, Bangalore. Targeted Temperature Management in TBI 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018
- 2. Bramlett HM, etal. J Cereb Blood Flow Metab, 2004. 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018
- 3. 3rd NSI SuperSpecialty CME on NeuroTrauma, Udaipur July 2018 Sayeed I, et al. Progress in Brain Research, 2009. Targeted Temperature Management in TBI
- 4. TTM Hypothermia 3rd NSI SuperSpecialty CME on NeuroTrauma, Udaipur July 2018 Sayeed I, et al. Progress in Brain Research, 2009. Targeted Temperature Management in TBI
- 5. Therapeutic Hypothermia – ClinicalEffects • Reduces brain metabolism (~ 6-8% per 1°C) and demand, restores a favourable balance with cerebral blood flow in injured brain • Lowers the intracranial pressure 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Cariou A, et al. Anaesth Crit Care Pain Med 2017. Targeted Temperature Management in TBI
- 6. Cooling Methods 3rd NSISuper Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI
- 7. Badjatia N, etal. NNSCNA 2013. Targeted Temperature Management in TBI 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Low K, Mg, PO4; Insulin resistance; Hypotension; Bradycardia; Coagulopathy.
- 8. Targeted Temperature Managementin TBI 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Badjatia N, et al. NNSCNA 2013.
- 9. TTM – EstablishedIndications American Heart Association (AHA) – Class 1 • Induce hypothermia for unconscious adult patients with return of spontaneous circulation after out-of-hospital cardiac arrest • The temperature should be maintained between 32°C and 36°C • Routine prehospital cooling of with IV rapid infusion is not advised Contraindications: • Recent major surgery within 14 days - Hypothermia may increase the risk of infection and bleeding. • Systemic infection/sepsis - Hypothermia may inhibit immune function and is associated with an increase in risk of infection. • Coma from other causes (drug intoxication, preexisting coma prior to arrest) • Known bleeding diathesis or with active ongoing bleeding Targeted Temperature Management in TBI 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018
- 10. TTM for TBI PetersonK, et al. J Neurotrauma, 2008. The small benefit with hypothermia is negated by the side effects 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI
- 11. BTF [3rd Edition] Recommendationson TTM • BTF – Level III (Optional) • Cautious use of hypothermia for adults • Not recommended for children • Local cooling of the brain and combination of hypothermia with drugs should be evaluated 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 BTF, 2007 Targeted Temperature Management in TBI
- 12. Recent Trial ofTTM in TBI • NABIS:H II - 2011 • Very early hypothermia induction in patients with severe brain injury (theNational Acute Brain Injury Study: Hypothermia II): a randomised trial • Eurotherm 3235 – 2015 • European society of intensive care medicine study of therapeutic hypothermia (32-35°C) for intracranial pressure reduction after traumatic brain injury • Brain-Hypothermia (B-HYPO) - 2015 • Prolonged Mild Therapeutic Hypothermia versus Fever Control with Tight Hemodynamic Monitoring and Slow Rewarming in Patients with Severe Traumatic Brain Injury: A Randomized Controlled Trial 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI
- 13. NABIS:H II –2011 • Planned sample size 240 from 2005 onwards • Terminated for futility in 2009 • 97 patients within 2.5 hours of injury were enrolled at the University of Texas • Hypothermia Induction: 2 L of cold crystalloid and application of wet sheets or gel packs • Maintained at 33°C for 48 h by surface cooling • Rewarmed by 0·5°C every 2 h 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI Clifton G, et al. Lancet Neurol 2011.
- 14. NABIS:H II 3rd NSISuper Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI Clifton G, et al. Lancet Neurol 2011.
- 15. NABIS:H II 3rd NSISuper Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI Clifton G, et al. Lancet Neurol 2011. The only complication that was increased in frequency in the hypothermia group compared with the normothermia group was episodes of increased ICP (p=0.003), which resulted in a significant increase in the total rate of complications in patients in the hypothermia group (p=0.01).
- 16. Eurotherm3235 Trial -2015 • Aimed to recruit 600 patients from18 countries from 2009 onwards • Recruitment was suspended in 2014 owing to safety • 387 patients at 47 centers • Hypothermia induction: bolus of IV refrigerated 0.9% NaCl (20 to 30 ml/ kg) • Maintained with the usual cooling technique for at least 48 hrs. • Rewarmed at 0.25°C per hour 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI Andrews PJD, et al. N Engl J Med 2015.
- 17. 3rd NSI SuperSpecialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI
- 18. Eurotherm3235 Trial 3rd NSISuper Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI Andrews PJD, et al. N Engl J Med 2015.
- 19. Eurotherm3235 Trial 3rd NSISuper Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI Andrews PJD, et al. N Engl J Med 2015.
- 20. Brain-Hypothermia (B-HYPO) -2015 •Within 6 h after the onset of TBI • TH (32–34°C) and fever control (35.5–37°C) • Hypothermia induction: Cooling blankets, rapid cold fluid infusion, and/or cold gastric lavage • Maintained for ≥72 h, using surface cooling blankets • Rewarmed at <1°C/day • Temperature was maintained at <38°C for 7 days after the onset of TBI 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI Maekawa,T, et al. Journal of Neurotrauma 2015.
- 21. Brain-Hypothermia (B-HYPO) -2015 3rdNSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI Maekawa,T, et al. Journal of Neurotrauma 2015.
- 22. BTF [4th Edition] Recommendationson TTM • Level I and II A • There was insufficient evidence to support a Level I or II A recommendation for this topic. • Level II B • Early (within 2.5 hours), short-term (48 hours post- injury) prophylactic hypothermia is not recommended to improve outcomes in patients with diffuse injury 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI BTF. 2016.
- 23. Hypothermia in Childrenwith TBI 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Zhang B, et al. World Neurosurg 2015.
- 24. Hypothermia in Childrenwith TBI 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Zhang B, et al. World Neurosurg 2015.
- 25. Fever • Cerebral metabolismincreased by 5-7% for each oC rise in temperature • Increased glucose & O2 consumption • Fever early after TBI associated with • Poor GCS on presentation • Presence of DAI and edema on the initial CT • Systolic hypotension • Hyperglycemia • Leukocytosis Badjatia N. Crit Care Med 2009 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018
- 26. Fever • Fever in1st week is associated with • Increased ICP • Neurologic impairment • Prolonged ICU stay • Intermediate decline • Long-term poor outcome Badjatia N. Crit Care Med 2009 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018
- 27. Ongoing Trials • LTH-1 •Randomized Controlled Trial of Long-term Mild Hypothermia for Severe Traumatic Brain Injury • Longer hyperthermia (34–35 °C) for 5 • HOPES • HypOthermia for Patients requiring Evacuation of Subdural Hematoma: A Multicenter, Randomized Clinical Trial • SDH preoperative induction for 48 h • POLAR • Prehospital hypothermia 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI
- 28. Summary • Evidence fromanimal models indicates that lowering temperature by few degrees can substantially produce neuroprotection. • Maintenance of normothermia and fever prevention after brain injury is generally considered a standard therapy in the ICU. • Ongoing clinical trials will inform us about the potential role of maintaining normothermia or inducing hypothermia in critically ill patients with a brain injury. • Future research should refine patient selection on the basis of biomarkers, and may use novel methods such as ultraselective brain cooling and pharmacologic thermomodulation. 3rd NSI Super Specialty CME on NeuroTrauma, Udaipur July 2018
- 29. 3rd NSI SuperSpecialty CME on NeuroTrauma, Udaipur July 2018 Targeted Temperature Management in TBI
- 30. 3rd NSI SuperSpecialty CME on NeuroTrauma, Udaipur July 2018 JS, et al. NEJM 2008.