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Management of shivering in hypothermia

Jonathan Marehbian, David M Greer
In the past two decades, there has been much focus on the adverse effect of fever on neurologic outcome, the benefits of hypothermia on functional outcomes, and the interplay of associated complications. Despite decades of experience regarding randomized, safety and feasibility, case-controlled, retrospective studies, there has yet to be a large, randomized, multicenter, clinical trial with the appropriate power to address the potential benefits of targeted temperature modulation compared to hypothermia alone...
January 2017: Current Treatment Options in Neurology
N Badjatia
The application of targeted temperature management has become common practice in the neurocritical care setting. It is important to recognize the pathophysiologic mechanisms by which temperature control impacts acute neurologic injury, as well as the clinical limitations to its application. Nonetheless, when utilizing temperature modulation, an organized approach is required in order to avoid complications and minimize side-effects. The most common clinically relevant complications are related to the impact of cooling on hemodynamics and electrolytes...
2017: Handbook of Clinical Neurology
Michael J Murray, Heidi DeBlock, Brian Erstad, Anthony Gray, Judi Jacobi, Che Jordan, William McGee, Claire McManus, Maureen Meade, Sean Nix, Andrew Patterson, M Karen Sands, Richard Pino, Ann Tescher, Richard Arbour, Bram Rochwerg, Catherine Friederich Murray, Sangeeta Mehta
OBJECTIVE: To update the 2002 version of "Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient." DESIGN: A Task Force comprising 17 members of the Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents; a Grading of Recommendations Assessment, Development, and Evaluation expert; and a medical writer met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines...
November 2016: Critical Care Medicine
Tomasz Gaszynski
INTRODUCTION: We report on the anesthetic management using opioid-free method of a patient with Steinert syndrome (myotonic dystrophy, MD), autosomal dominant dystrophy which is characterized by consistent contracture of muscle following stimulation. A myotonic crisis can be induced by numerous factors including hypothermia, shivering, and mechanical or electrical stimulation. In patients with MD, hypersensitivity to anesthetic drugs, especially muscle relaxants and opioids, may complicate postoperative management...
September 2016: Medicine (Baltimore)
Courtney J Cook
Induced hypothermia (IH) continues to become a more prevalent treatment modality in neurocritical care. Reducing core temperature has been shown to protect brain tissue during injury and disease. IH has been particularly beneficial in the medical management of refractory intracranial hypertension and malignant cerebral edema. These pathologies are often the result of diffuse cerebral edema after traumatic brain injury, malignant ischemic stroke, or intracerebral hemorrhage. Although there are many benefits to IH, it is not without complications...
September 5, 2016: Journal of Neuroscience Nursing: Journal of the American Association of Neuroscience Nurses
Yasuhiro Kuroda
This update comprises six important topics under neurocritical care that require reevaluation. For post-cardiac arrest brain injury, the evaluation of the injury and its corresponding therapy, including temperature modulation, is required. Analgosedation for target temperature management is an essential strategy to prevent shivering and minimizes endogenous stress induced by catecholamine surges. For severe traumatic brain injury, the diverse effects of therapeutic hypothermia depend on the complicated pathophysiology of the condition...
2016: Journal of Intensive Care
Eva Madrid, Gerard Urrútia, Marta Roqué i Figuls, Hector Pardo-Hernandez, Juan Manuel Campos, Pilar Paniagua, Luz Maestre, Pablo Alonso-Coello
BACKGROUND: Inadvertent perioperative hypothermia is a phenomenon that can occur as a result of the suppression of the central mechanisms of temperature regulation due to anaesthesia, and of prolonged exposure of large surfaces of skin to cold temperatures in operating rooms. Inadvertent perioperative hypothermia has been associated with clinical complications such as surgical site infection and wound-healing delay, increased bleeding or cardiovascular events. One of the most frequently used techniques to prevent inadvertent perioperative hypothermia is active body surface warming systems (ABSW), which generate heat mechanically (heating of air, water or gels) that is transferred to the patient via skin contact...
April 21, 2016: Cochrane Database of Systematic Reviews
Djillali Annane
Neuromuscular blocking agents and corticosteroids are widely used in medicine and in particular in the intensive care unit (ICU). Neuromuscular blockade is commonly used to ease tracheal intubation, to optimize mechanical ventilation and oxygenation in acute respiratory disorders such as status asthmaticus and acute respiratory distress syndrome (ARDS), to prevent shivering during therapeutic hypothermia, and also in patients with elevated intracranial pressure. In the ICU, patients with sepsis, ARDS, community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, severe asthma, or trauma may receive corticosteroids...
February 2016: Seminars in Respiratory and Critical Care Medicine
Akilesh Honasoge, Braden Parker, Kelly Wesselhoff, Neal Lyons, Erik Kulstad
Therapeutic hypothermia or targeted temperature management has been used after cardiac arrest to improve neurological outcomes and mortality. However, a side effect of temperature modulation is a centrally mediated shivering response. The Columbia Anti-Shivering Protocol sets up a systematic method of intravenous (IV) and oral medication escalation to suppress this response and preserve the benefits of this therapy. We present the case of a 59-year-old male who began shivering after therapeutic hypothermia for cardiac arrest, leading to a persistent rise in core temperature despite adequate sedation...
March 2016: Therapeutic Hypothermia and Temperature Management
William P Cheshire
Thermoregulation is a vital function of the autonomic nervous system in response to cold and heat stress. Thermoregulatory physiology sustains health by keeping body core temperature within a degree or two of 37°C, which enables normal cellular function. Heat production and dissipation are dependent on a coordinated set of autonomic responses. The clinical detection of thermoregulatory impairment provides important diagnostic and localizing information in the evaluation of disorders that impair thermoregulatory pathways, including autonomic neuropathies and ganglionopathies...
April 2016: Autonomic Neuroscience: Basic & Clinical
Katlynd M Šunjić, Adam C Webb, Igor Šunjić, Mònica Palà Creus, Stacey L Folse
OBJECTIVE: To synthesize an emerging body of literature describing pharmacokinetic alterations and related pharmacodynamic implications affecting drugs commonly used in patients receiving targeted temperature management following cardiac arrest. DATA SOURCES: Peer-reviewed articles indexed in PubMed. STUDY SELECTION: A systematic search of the PubMed database for relevant preclinical studies and clinical and observational trials of physiologic changes and drug pharmacokinetic and pharmacodynamic alterations, especially during targeted temperature management/therapeutic hypothermia, but also from cardiac surgery and acute stroke hypothermia models...
October 2015: Critical Care Medicine
Tulasi R Jinka, Velva M Combs, Kelly L Drew
Therapeutic hypothermia (TH) improves prognosis after cardiac arrest; however, thermoregulatory responses such as shivering complicate cooling. Hibernators exhibit a profound and safe reversible hypothermia without any cardiovascular side effects by lowering the shivering threshold at low ambient temperatures (Ta). Activation of adenosine A1 receptors (A1ARs) in the central nervous system (CNS) induces hibernation in hibernating species and a hibernation-like state in rats, principally by attenuating thermogenesis...
June 17, 2015: ACS Chemical Neuroscience
Kathleen Ryan Avery, Molly O'Brien, Carol Daddio Pierce, Priscilla K Gazarian
Therapeutic hypothermia has become a widely accepted intervention that is improving neurological outcomes following return of spontaneous circulation after cardiac arrest. This intervention is highly complex but infrequently used, and prompt implementation of the many steps involved, especially achieving the target body temperature, can be difficult. A checklist was introduced to guide nurses in implementing the therapeutic hypothermia protocol during the different phases of the intervention (initiation, maintenance, rewarming, and normothermia) in an intensive care unit...
February 2015: Critical Care Nurse
Judy Munday, Sonia Hines, Karen Wallace, Anne M Chang, Kristen Gibbons, Patsy Yates
BACKGROUND: Women undergoing cesarean section are vulnerable to adverse effects associated with inadvertent perioperative hypothermia, but there has been a lack of synthesized evidence for temperature management in this population. This systematic review aimed to synthesize the best available evidence in relation to preventing hypothermia in mothers undergoing cesarean section surgery. METHODS: Randomized controlled trials meeting the inclusion criteria (adult patients of any ethnic background, with or without comorbidities, undergoing any mode of anesthesia for any type of cesarean section) were eligible for consideration...
December 2014: Worldviews on Evidence-based Nursing
Kenichiro Koda, Takayuki Kitamura, Megumi Tagami
General anesthesia using remifentanil is accompanied with post-operative shivering at a high incidence. Post-operative shivering can be divided into thermoregulatory and non-thermoregulatory. Hypothermia causes thermoregulatory shivering. The interthreshold range is defined as the difference between the sweating threshold and the vasoconstriction threshold. Generally, the interthreshold range is shifted to higher temperatures immediately after surgery under general anesthesia. Thus, thermoregulatory shivering can be exaggerated in patients without hypothermia...
September 2014: Masui. the Japanese Journal of Anesthesiology
Jean Baptiste Lascarrou, Amélie Le Gouge, Jérome Dimet, Jean Claude Lacherade, Laurent Martin-Lefèvre, Maud Fiancette, Isabelle Vinatier, Christine Lebert, Konstantinos Bachoumas, Aihem Yehia, Matthieu Henry Lagarrigue, Gwenhael Colin, Jean Reignier
INTRODUCTION: Neuromuscular blockade (NMB) is widely used during therapeutic hypothermia (TH) after cardiac arrest but its effect on patient outcomes is unclear. We compared the effects of NMB on neurological outcomes and frequency of early-onset pneumonia in cardiac-arrest survivors managed with TH. METHODS: We retrospectively studied consecutive adult cardiac-arrest survivors managed with TH in a tertiary-level intensive care unit between January 2008 and July 2013...
September 2014: Resuscitation
Jin Hwan Lee, Ling Wei, Xiaohuan Gu, Zheng Wei, Thomas A Dix, Shan Ping Yu
Preclinical and clinical studies have shown therapeutic potential of mild-to-moderate hypothermia for treatments of stroke and traumatic brain injury (TBI). Physical cooling in humans, however, is usually slow, cumbersome, and necessitates sedation that prevents early application in clinical settings and causes several side effects. Our recent study showed that pharmacologically induced hypothermia (PIH) using a novel neurotensin receptor 1 (NTR1) agonist, HPI-201 (also known as ABS-201), is efficient and effective in inducing therapeutic hypothermia and protecting the brain from ischemic and hemorrhagic stroke in mice...
August 15, 2014: Journal of Neurotrauma
Bhupinder Jit K Sran, Gerren K McDonald, Alan M Steinman, Phillip F Gardiner, Gordon G Giesbrecht
OBJECTIVE: The purpose of the study was to compare the effectiveness of head vs torso warming in rewarming mildly hypothermic, vigorously shivering subjects using a similar source of heat donation. METHODS: Six subjects (1 female) were cooled on 3 occasions in 8 ºC water for 60 minutes or to a core temperature of 35 ºC. They were then dried, insulated, and rewarmed by 1) shivering only; 2) charcoal heater applied to the head; or 3) charcoal heater applied to the torso...
March 2014: Wilderness & Environmental Medicine
Adam M Noyes, Justin B Lundbye
Mild therapeutic hypothermia (MTH) is used to lower the core body temperature of cardiac arrest (CA) patients to 32°C from 34°C to provide improved survival and neurologic outcomes after resuscitation from in-hospital or out-of-hospital CA. Despite the improved benefits of MTH, there are potentially unforeseen complications associated during management. Although the adverse effects are transient, the clinician should be aware of the associated complications when managing the patient receiving MTH. We aim to provide the medical community comprehensive information related to the potential complications of survivors of CA receiving MTH, as it is imperative for the clinician to understand the physiologic changes that take place in the patient receiving MTH and how to prepare for them and manage them if they do occur...
July 2015: Journal of Intensive Care Medicine
Ivan Rocha Ferreira Da Silva, Jennifer Ann Frontera
Mild therapeutic hypothermia (MTH) results in a significant decrease in mortality and improvement of neurologic outcomes in cardiac arrest (CA) survivors. Cardiologists and intensivists must be acquainted with the indications and technique because MTH is the only proven neuroprotective therapy for CA survivors. CA involves reinstituting meaningful cardiac activity and minimizing secondary neurologic injuries. This article focuses on MTH as the main strategy for post-CA care.
November 2013: Cardiology Clinics
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