Implementation of Targeted Temperature Management
Publication Date: October 1, 2017
Recommendations
Induction and Maintenance of TTM
We suggest at least 24 h of cooling in out-of-hospital cardiac arrest (OHCA) patients. ( Conditional , Moderate )
607
We suggest longer duration targeted temperature management (TTM) for severe traumatic brain injury (TBI) patients should increased intracranial pressure (ICP) control be the goal. ( Conditional , Low )
607
We advise against longer (>72 h) or deeper (<32.0 °C) hypothermia in neonates with hypoxic-ischemic encephalopathy (HIE). ( Conditional , Moderate )
607
We cannot recommend any specific timing of TTM initiation (prophylactic or symptom-based), due to equivocal evidence about its impact on length of stay, ICP burden, and neurologic outcome.
We recommend using controlled normothermia to reduce fever burden in patients with fever refractory to conventional therapy. ( Strong , Moderate )
We recommend using controlled normothermia to reduce fever burden in patients with fever refractory to conventional therapy. ( Strong , Moderate )
607
We recommend using intranasal, surface, or intravascular temperature-modulating devices and/or cold saline infusions over air cooling blankets, cooling fans, or cooling packs to achieve faster time to target temperature, improve the likelihood of achieving target temperature, and lessen the likelihood of overshoot. ( Strong , High )
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We recommend using surface cooling devices over passive air cooling and/or ice packs to increase the likelihood of achieving target temperature in neonatal patients with hypoxic-ischemic encephalopathy. ( Strong , High )
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To maintain constant patient temperature, we recommend using intravascular catheters, or gel pads if such catheters are not available. ( Strong , High )
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To minimize temperature variability in neonates with HIE, we suggest using a servo-controlled body wrap over conventional measures. ( Conditional , Low )
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To minimize overshoot, we recommend gel pads over conventional measures. ( Strong , Moderate )
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To minimize overshoot, we suggest using temperature modulating devices with servo-controls and gradient temperature changes. ( Conditional , Low )
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We suggest using an esophageal temperature probe during all phases of TTM. If an esophageal probe is not appropriate or available, we suggest using a bladder temperature probe. ( Conditional , Low )
607
Shivering
Clinicians and researchers should consider using a shivering assessment tool. (, )
(Good practice statement)
607
Of the tools available, we recommend the e Bedside Shiver Assessment Scale (BSAS) because of its established accuracy and inter-rater reliability. ( Strong , Moderate )
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Clinicians should treat shivering promptly We suggest a stepwise approach to shivering which prioritizes non-sedating interventions (acetaminophen, counterwarming, magnesium) over narcotic analgesics, sedatives, or paralytics. (, )
(Good practice statement)
607
Clinicians should be aware of the impact that TTM may have upon metabolism and substrate utilization. Metabolic support should be driven by the disease state and actual measurement of metabolism. (, )
(Good practice statement)
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Complications
We suggest that no additional measures be considered to avoid gastric intolerance in patients undergoing TTM. ( Conditional , Low )
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We suggest that clinicians adhere to standard critical care guidelines when monitoring for infection in patients undergoing TTM. ( Conditional , Low )
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We recommend maintaining serum potassium levels between 3.0 and 3.5 mmol/L during induction and maintenance phases to prevent rebound hyperkalemia and arrhythmias during rewarming. ( Strong , High )
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Arterial blood gas measurements should be temperature-corrected. (, )
(Good practice statement)
607
Clinical monitoring for other laboratory abnormalities during cooling should be similar to that for any critically ill patient. (, )
(Good practice statement)
607
As with standard intensive care practice, clinicians should monitor the therapeutic efficacy of drugs and measure serum concentrations where possible.
Given that the pharmacokinetics of commonly used analgesics and sedatives may be altered by cooling, clinicians should consider their potentially long-lasting impact on neurologic assessments during TTM. (, )
Given that the pharmacokinetics of commonly used analgesics and sedatives may be altered by cooling, clinicians should consider their potentially long-lasting impact on neurologic assessments during TTM. (, )
(Good practice statement)
607
We strongly recommend no change in routine care with respect to monitoring for bleeding and preventing thrombosis in TTM patients. ( Strong , High )
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We suggest that thromboelastometry may be helpful in measuring coagulation and platelet aggregation in TTM patients. ( Conditional , Low )
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Clinicians should consider daily mobilization for all TTM patients. (, )
(Good practice statement)
607
We suggest increased vigilance for skin breakdown when using surface cooling devices in patients with shock or left ventricular failure. ( Conditional , Low )
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We recommend cardiac monitoring during TTM, particularly during hypothermia. ( Strong , High )
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Because of the lack of evidence for increased risk, we do not recommend a change to routine monitoring for other complications, including renal failure, ARDS, GI-tract impairment, hypotension, DVT, days intubated and seizures. ( Strong , High )
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Recommendation Grading
Disclaimer
Overview
Title
Implementation of Targeted Temperature Management
Authoring Organization
Neurocritical Care Society
Publication Month/Year
October 1, 2017
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This guideline is to provide guidelines for Targeted temperature management on selecting appropriate cooling techniques, providing a reasonable rate of cooling, managing shivering, and ensuring adequate patient monitoring among other challenges.
Target Patient Population
Patients who required targeted temperature management
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Emergency care, Hospital, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D000758 - Anesthesia, D018681 - Anesthetics, General, D001831 - Body Temperature, D001833 - Body Temperature Regulation, D007036 - Hypothermia, Induced
Keywords
anesthesia, critical care, targeted temperature management
Source Citation
Neurocritical Care volume 27, pages468–487(2017)
Supplemental Methodology Resources
Methodology
Number of Source Documents
205
Literature Search Start Date
November 1, 2016
Literature Search End Date
March 1, 2017