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Yang ZJ, Hopkins CD, Santos PT, Adams S, Kulikowicz E, Lee JK, Tandri H, Koehler RC. Neuroprotection provided by hypothermia initiated with high transnasal flow with ambient air in a model of pediatric cardiac arrest. Am J Physiol Regul Integr Comp Physiol 2024; 327:R304-R318. [PMID: 38860282 DOI: 10.1152/ajpregu.00078.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/28/2024] [Accepted: 06/05/2024] [Indexed: 06/12/2024]
Abstract
Clinical trials of hypothermia after pediatric cardiac arrest (CA) have not seen robust improvement in functional outcome, possibly because of the long delay in achieving target temperature. Previous work in infant piglets showed that high nasal airflow, which induces evaporative cooling in the nasal mucosa, reduced regional brain temperature uniformly in half the time needed to reduce body temperature. Here, we evaluated whether initiation of hypothermia with high transnasal airflow provides neuroprotection without adverse effects in the setting of asphyxic CA. Anesthetized piglets underwent sham-operated procedures (n = 7) or asphyxic CA with normothermic recovery (38.5°C; n = 9) or hypothermia initiated by surface cooling at 10 (n = 8) or 120 (n = 7) min or transnasal cooling initiated at 10 (n = 7) or 120 (n = 7) min after resuscitation. Hypothermia was sustained at 34°C with surface cooling until 20 h followed by 6 h of rewarming. At 4 days of recovery, significant neuronal loss occurred in putamen and sensorimotor cortex. Transnasal cooling initiated at 10 min significantly rescued the number of viable neurons in putamen, whereas levels in putamen in other hypothermic groups remained less than sham levels. In sensorimotor cortex, neuronal viability in the four hypothermic groups was not significantly different from the sham group. These results demonstrate that early initiation of high transnasal airflow in a pediatric CA model is effective in protecting vulnerable brain regions. Because of its simplicity, portability, and low cost, transnasal cooling potentially could be deployed in the field or emergency room for early initiation of brain cooling after pediatric CA.NEW & NOTEWORTHY The onset of therapeutic hypothermia after cardiac resuscitation is often delayed, leading to incomplete neuroprotection. In an infant swine model of asphyxic cardiac arrest, initiation of high transnasal airflow to maximize nasal evaporative cooling produced hypothermia sufficient to provide neuroprotection that was not inferior to body surface cooling. Because of its simplicity and portability, this technique may be of use in the field or emergency room for rapid brain cooling in pediatric cardiac arrest victims.
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Affiliation(s)
- Zeng-Jin Yang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - C Danielle Hopkins
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Polan T Santos
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Shawn Adams
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Ewa Kulikowicz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Harikrishna Tandri
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
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Arnold S, Armahizer M, Torres LF, Tripathi H, Tandri H, Chang JJ, Choi HA, Badjatia N. Minimizing Shivering During Targeted Normothermia: Comparison Between Novel Transnasal and Surface Temperature-Modulating Devices. Neurocrit Care 2023; 39:639-645. [PMID: 37498457 DOI: 10.1007/s12028-023-01793-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/21/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Shivering is a common adverse effect of achieving and maintaining normothermia in neurocritical care patients. We compared the burden of shivering and shivering-related interventions between a novel transnasal temperature-modulating device (tnTMD) and surface cooling temperature-modulating devices (sTMDs) during the first 24 h of targeted normothermia in mechanically ventilated febrile neurocritical care patients. METHODS This is a case-control study controlling for factors that impact shiver burden: age, sex, body surface area. All patients underwent transnasal cooling (CoolStat, KeyTech, Inc.) as part of an ongoing multicenter clinical trial (NCT03360656). Patients undergoing treatment with sTMDs were selected from consecutively treated patients during the same time period. Data collected included the following: core body temperature (every 2 h), bedside shivering assessment scale (BSAS) score (every 2 h), and administration of antishivering medication for a BSAS score > 1. Time to normothermia (≤ 37.5 °C), as well as temperature burden > 37.5 °C (°C × h), were compared between groups using Student's t-test for mean differences. The proportion of patients requiring interventions, as well as the number of interventions per patient, was compared using the χ2 test. Significance was determined based on a p value < 0.05. RESULTS There were 10 tnTMD patients and 30 sTMD patients included in the analysis (mean age: 62 ± 4, 30% women, body surface area = 1.97 ± 0.25). There were no differences between groups in temperature at cooling initiation (tnTMD: 38.5 ± 0.2 °C vs. sTMD: 38.7 ± 0.5 °C, p = 0.3), time to ≤ 37.5 °C (tnTMD: 1.8 ± 1.5 h vs. sTMD: 2.9 ± 1.4 h, p = 0.1), or temperature burden > 37.5 (tnTMD: - 0.4 ± 1.13 °C × h vs. sTMD median [IQR]: - 0.57 ± 0.58 °C × h, p = 0.67). The number of tnTMD patients who received pharmacologic shivering interventions was lower than the number of controls (20 vs. 67%, p = 0.01). tnTMD patients also had fewer shivering interventions per patient (0 [range: 0-3] vs. 4 [range: 0-23], p < 0.001). CONCLUSIONS A transnasal cooling approach achieved similar time to normothermia and temperature burden with less shivering than surface cooling. This approach may be a feasible option to consider for mechanically ventilated febrile neurocritical care patients.
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Affiliation(s)
- Shannon Arnold
- Program in Trauma, Shock Trauma Neurocritical Care, Department of Neurology, University of Maryland School of Medicine, 22 S. Greene Street, G7K19, Baltimore, MD, 21201, USA
| | - Michael Armahizer
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, USA
| | - Luis F Torres
- Department of Cardiology, The Johns Hopkins Hospital, Baltimore, USA
| | - Hemant Tripathi
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington D.C., USA
- Department of Neurology, Georgetown University, Washington D.C., USA
| | - Harikrishna Tandri
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington D.C., USA
- Department of Neurology, Georgetown University, Washington D.C., USA
| | - Jason J Chang
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, USA
| | - H Alex Choi
- Department of Cardiology, The Johns Hopkins Hospital, Baltimore, USA
| | - Neeraj Badjatia
- Program in Trauma, Shock Trauma Neurocritical Care, Department of Neurology, University of Maryland School of Medicine, 22 S. Greene Street, G7K19, Baltimore, MD, 21201, USA.
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Legriel S. Commentary on Minimizing Shivering During Targeted Normothermia. Neurocrit Care 2023; 39:553-554. [PMID: 37537497 DOI: 10.1007/s12028-023-01810-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Stephane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay, France.
- IctalGroup, 78150, Le Chesnay, France.
- Paris-Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, Institut national de la santé et de la recherche médicale, Centre de recherche en épidémiologie et santé des populations, 94800, Villejuif, France.
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Baker TS, Kellner CP, Colbourne F, Rincon F, Kollmar R, Badjatia N, Dangayach N, Mocco J, Selim MH, Lyden P, Polderman K, Mayer S. Consensus recommendations on therapeutic hypothermia after minimally invasive intracerebral hemorrhage evacuation from the hypothermia for intracerebral hemorrhage (HICH) working group. Front Neurol 2022; 13:859894. [PMID: 36062017 PMCID: PMC9428129 DOI: 10.3389/fneur.2022.859894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/30/2022] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Therapeutic hypothermia (TH), or targeted temperature management (TTM), is a classic treatment option for reducing inflammation and potentially other destructive processes across a wide range of pathologies, and has been successfully used in numerous disease states. The ability for TH to improve neurological outcomes seems promising for inflammatory injuries but has yet to demonstrate clinical benefit in the intracerebral hemorrhage (ICH) patient population. Minimally invasive ICH evacuation also presents a promising option for ICH treatment with strong preclinical data but has yet to demonstrate functional improvement in large randomized trials. The biochemical mechanisms of action of ICH evacuation and TH appear to be synergistic, and thus combining hematoma evacuation with cooling therapy could provide synergistic benefits. The purpose of this working group was to develop consensus recommendations on optimal clinical trial design and outcomes for the use of therapeutic hypothermia in ICH in conjunction with minimally invasive ICH evacuation. Methods An international panel of experts on the intersection of critical-care TH and ICH was convened to analyze available evidence and form a consensus on critical elements of a focal cooling protocol and clinical trial design. Three focused sessions and three full-group meetings were held virtually from December 2020 to February 2021. Each meeting focused on a specific subtopic, allowing for guided, open discussion. Results These recommendations detail key elements of a clinical cooling protocol and an outline for the roll-out of clinical trials to test and validate the use of TH in conjunction with hematoma evacuation as well as late-stage protocols to improve the cooling approach. The combined use of systemic normothermia and localized moderate (33.5°C) hypothermia was identified as the most promising treatment strategy. Conclusions These recommendations provide a general outline for the use of TH after minimally invasive ICH evacuation. More research is needed to further refine the use and combination of these promising treatment paradigms for this patient population.
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Affiliation(s)
- Turner S. Baker
- Icahn School of Medicine at Mount Sinai, Sinai BioDesign, New York, NY, United States
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Turner S. Baker
| | - Christopher P. Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Fred Rincon
- Department of Neurology, Thomas Jefferson University Hospital, Thomas Jefferson University, Philadelphia, PA, United States
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Germany
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Neha Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - J. Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Magdy H. Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, United States
| | - Patrick Lyden
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, CA, United States
| | - Kees Polderman
- United Memorial Medical Center, Houston, TX, United States
| | - Stephan Mayer
- Westchester Medical Center Health Network, Valhalla, NY, United States
- Department of Neurology, New York Medical College, Valhalla, NY, United States
- Department of Neurosurgery, New York Medical College, Valhalla, NY, United States
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Dibu JR, Haque R, Shoshan S, Abulhasan YB. Treatment of Fever in Neurologically Critically Ill Patients. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00732-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Duh M, Skok K, Perc M, Markota A, Gosak M. Computational modeling of targeted temperature management in post-cardiac arrest patients. Biomech Model Mechanobiol 2022; 21:1407-1424. [PMID: 35763192 DOI: 10.1007/s10237-022-01598-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Abstract
Our core body temperature is held around [Formula: see text]C by an effective internal thermoregulatory system. However, various clinical scenarios have a more favorable outcome under external temperature regulation. Therapeutic hypothermia, for example, was found beneficial for the outcome of resuscitated cardiac arrest patients due to its protection against cerebral ischemia. Nonetheless, practice shows that outcomes of targeted temperature management vary considerably in dependence on individual tissue damage levels and differences in therapeutic strategies and protocols. Here, we address these differences in detail by means of computational modeling. We develop a multi-segment and multi-node thermoregulatory model that takes into account details related to specific post-cardiac arrest-related conditions, such as thermal imbalances due to sedation and anesthesia, increased metabolic rates induced by inflammatory processes, and various external cooling techniques. In our simulations, we track the evolution of the body temperature in patients subjected to post-resuscitation care, with particular emphasis on temperature regulation via an esophageal heat transfer device, on the examination of the alternative gastric cooling with ice slurry, and on how anesthesia and the level of inflammatory response influence thermal behavior. Our research provides a better understanding of the heat transfer processes and therapies used in post-cardiac arrest patients.
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Affiliation(s)
- Maja Duh
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koroška cesta 160, 2000, Maribor, Slovenia
| | - Kristijan Skok
- Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.,Department of Pathology, General Hospital Graz II, Location West, Göstinger Straße 22, 8020, Graz, Austria
| | - Matjaž Perc
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koroška cesta 160, 2000, Maribor, Slovenia.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, 404332, Taiwan.,Alma Mater Europaea, Slovenska ulica 17, 2000, Maribor, Slovenia.,Complexity Science Hub Vienna, Josefstädterstraße 39, 1080, Vienna, Austria
| | - Andrej Markota
- Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.,Medical Intensive Care Unit, University Medical Centre Maribor, Ljubljanska 5, 2000, Maribor, Slovenia
| | - Marko Gosak
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koroška cesta 160, 2000, Maribor, Slovenia. .,Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.
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