Antipyretic treatment of noninfectious fever in children with severe traumatic brain injury

Targeted Temperature Management Protocol in a Pediatric Intensive Care Unit: A Quality Improvement Project

BACKGROUND

In patients with acute neurological injury, abrupt temperature change exacerbates increased intracranial pressures and negatively affects perfusion pressure and cerebral blood flow. Critical care nurses must provide coordinated and effective interventions to maintain normothermia without precipitating shivering immediately after acute neurological injury in pediatric patients.

OBJECTIVE

To improve hyperthermia management in a 40-bed pediatric intensive care unit, an interdisciplinary pediatric critical care team developed, implemented, and evaluated a targeted temperature management protocol.

METHODS

The project was guided by the organization's plan-do-study-act quality improvement process. Quality improvement was assessed retrospectively using electronic medical records of patients meeting eligibility criteria. Samples of pediatric patients who received temperature interventions were compared before and after protocol implementation. The protocol included environmental, pharmacological, and body surface cooling device interventions, as well as use of a bedside shivering assessment scale and stepwise interventions to prevent and control shivering.

RESULTS

Before implementation of the targeted temperature management protocol, 64% of patients had documented temperatures higher than 37.5 °C, and body surface cooling devices were used in 10% of patients. After protocol implementation, more than 80% of patients had documented temperatures higher than 37.5 °C, and body surface cooling devices were used in 62% of patients. Four patients (6%) before and 5 patients (31%) after protocol implementation were treated with body surface cooling without requiring use of neuromuscular blockade.

CONCLUSIONS

Creation and implementation of a targeted temperature management protocol increased nurses' documented use of body surface cooling to manage hyperthermia in pediatric intensive care unit patients with acute neurological injury.

Paroxysmal Sympathetic Hyperactivity in Children: An Exploratory Evaluation of Nursing Interventions

BACKGROUND

Paroxysmal sympathetic hyperactivity (PSH) produces symptoms of autonomic instability and muscle over-activity; however, the majority of nursing interventions used in clinical practice are anecdotal and not evidenced based.

OBJECTIVE

The primary objective was to report nursing documentation of PSH events, and to describe the clinical nursing interventions and care provided to children who have suffered a severe brain injury and are exhibiting PSH. The secondary objective was to demonstrate how the Symptom Management Theory (SMT) can serve as a framework for research related to brain injury and PSH.

METHODOLOGY

The study consisted of a retrospective chart review of nursing progress notes using direct content analysis. The nested sample of ten randomly selected charts was chosen from a larger quantitative study of 83 children who had suffered severe brain injuries with and without PSH. Textual analysis of verbatim nursing progress notes was used to describe nursing interventions that were used and documented for this patient population.

RESULTS

The priority nursing interventions to manage these symptoms included medication administration, facilitation of family presence, and strategies to target auditory, tactile, and visual stimuli. The sample received different individual interventions for PSH. Additionally, individual subjects demonstrated different patterns of interventions.

IMPLICATIONS

While tactile interventions were documented most frequently, there was not a uniform approach to interventions. The SMT can be useful to provide a framework that organizes and tests clinical care and management of PSH strategies.

Paroxysmal sympathetic hyperactivity: Autonomic instability and muscle over-activity following severe brain injury

BACKGROUND

Children who suffer from moderate-to-severe brain injury can develop a complicating phenomenon known as paroxysmal sympathetic hyperactivity (PSH), characterized by autonomic instability and identified clinically as a cluster of symptoms that can include recurrent fever without a source of infection, hypertension, tachycardia, tachypnea, agitation, diaphoresis and dystonia. Studies with adults have demonstrated that this cluster of symptoms is associated with poorer clinical outcomes (prolonged hospitalizations, poorer cognitive and motor function). However, there have been limited studies in children with PSH.

OBJECTIVE

To present a literature review regarding PSH following severe brain injury and highlight research needs in children with PSH.

METHODOLOGY

Electronic databases (CINAHL, Ovid Medline, Web of Science and Google Scholar) were searched.

RESULTS

Thirty-one research articles met the criteria for inclusion. Several themes emerged regarding the phenomenon of interest during the review: nomenclature, symptoms, management and differences between children and adults.

IMPLICATIONS

The majority of the research regarding PSH following severe brain injury has been descriptive in nature. Few studies, however, have explored PSH in children with brain injury; therefore, little is known about whether the outcomes of children with PSH are different and, if so, in what ways.

The Effect of Paracetamol on Core Body Temperature in Acute Traumatic Brain Injury: A Randomised, Controlled Clinical Trial

Background

Strategies to prevent pyrexia in patients with acute neurological injury may reduce secondary neuronal damage. The aim of this study was to determine the safety and efficacy of the routine administration of 6 grams/day of intravenous paracetamol in reducing body temperature following severe traumatic brain injury, compared to placebo.

Methods

A multicentre, randomised, blind, placebo-controlled clinical trial in adult patients with traumatic brain injury (TBI). Patients were randomised to receive an intravenous infusion of either 1g of paracetamol or 0.9% sodium chloride (saline) every 4 hours for 72 hours. The primary outcome was the mean difference in core temperature during the study intervention period.

Results

Forty-one patients were included in this study: 21 were allocated to paracetamol and 20 to saline. The median (interquartile range) number of doses of study drug was 18 (17–18) in the paracetamol group and 18 (16–18) in the saline group (P = 0.85). From randomisation until 4 hours after the last dose of study treatment, there were 2798 temperature measurements (median 73 [67–76] per patient). The mean ± standard deviation temperature was 37.4±0.5°C in the paracetamol group and 37.7±0.4°C in the saline group (absolute difference -0.3°C; 95% confidence interval -0.6 to 0.0; P = 0.09). There were no significant differences in the use of physical cooling, or episodes of hypotension or hepatic abnormalities, between the two groups.

Conclusion

The routine administration of 6g/day of intravenous paracetamol did not significantly reduce core body temperature in patients with TBI.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12609000444280