Hypothermia and coagulation

Polderman

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• Publié par: biomed
• Publié le: 01 janvier 2012
• Nombre de lectures: 11
• Langue: English
• Poids de l'ouvrage: 1 Mo

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Critical Care 2012, Volume 16 Suppl 2
http://ccforum.com/supplements/16/S2
MEETING ABSTRACTS Open Access
Update on therapeutic temperature management
Portoroz, Slovenia. 7-9 June 2012
Edited by Gregor Broessner, Marlene Fischer, Gerrit Schubert, Bernhard Metzler and Erich Schmutzhard
Published: 7 June 2012
These abstracts are available online at http://ccforum.com/supplements/16/S2
protection, uncontrolled body temperatures possibly adding - per se-toINTRODUCTION
neuronal damage. Knowing the medical literature and knowing the issue
of potentially life-threatening side effects and complications incurred by
A1
this invasive therapeutic manoeuvre, it is the foremost aim of this
Update on therapeutic temperature management
symposium and this supplementary issue of Critical Care to discuss all1* 1 2 3Gregor Broessner , Marlene Fischer , Gerrit Schubert , Bernhard Metzler ,
1 these aspects of targeted temperature management in emergency, critical
Erich Schmutzhard
care and, in particular, neurocritical patients and conditions. For this reason1Department of Neurology, Medical University, Innsbruck, Austria;
the organisers have agreed that the discussion of these various issues,2 of Neurosurgery, Medical University, Austria;
3 being so important for general critical care, neurocritical care and of Cardiology, Medical University, Innsbruck, Austria
emergency medicine, must be distributed as widely as possible, making it
Critical Care 2012, 16(Suppl 2):A1
available to critical care and neurocritical care specialists all over the world.
Therefore we are extremely grateful to the Editors of Critical Care for
It is a pleasure to announce the 2nd Innsbruck Hypothermia Symposium.
providing a forum for all of the extended abstracts of all invited speakers,
We are very happy that Critical Care has agreed to publish extended
covering the entire field of adult emergency and critical care medicine. We
abstracts submitted by invited renowned scientists from all over the world;
do hope and we are convinced that this supplementary issue will be a
that is, Europe, the Americas, Asia. Neuroprotection - potentially achieved
source of inspiration and knowledge, hopefully becoming a work of
by targeted temperature management (that is, therapeutic hypothermia or
reference for intensivists, neurologists, neurointensivists, cardiologists and
prophylactic controlled normothermia) - is essential in emergency and
all emergency physicians alike. It is the aim of the organisers to establish a
acute care management of various severe neurologic and cardiologic
series of such symposia within the next years in order to keep up with all
diseases. Beyond neuroprotection - for this aim, therapeutic hypothermia
the developments in this field and to maintain the highest possible level of
has been established after resuscitation of patients with cardiac arrest due
knowledge of targeted temperature management in the community of
to a shockable arrhythmia and in neonatal asphyxic encephalopathy -
emergency and intensive care physicians.
therapeutic hypothermia and prophylactic controlled normothermia have
been published in single case reports, retrospective, open, but also in
prospective randomised controlled trials in many other emergency EMERGENCY TEMPERATUREdisciplines in which both neuroprotection and protection of other organs
and tissues are the target of our therapeutic endeavours. The Medical MANAGEMENT
University Innsbruck, Austria, is happy to organise this conference on
temperature management, therapeutic hypothermia and prophylactic A2
normothermia respectively, to be held in Portoroz, Slovenia. In accordance Therapeutic hypothermia: the rationale
*with the first Meeting on Hypothermia,whichwasheldinMiami,Florida, Erich Schmutzhard , Marlene Fischer, Anelia Dietmann, Gregor Brössner
USA (CHilling At the Beach), we are proud to suggest the acronym CHAB Department of Neurology, Neurocritical Care Unit, Medical University
standing for take Care for Heart And Brain, characterising the major target Innsbruck, Austria
organs of therapeutic and, possibly also, prophylactic temperature Critical Care 2012, 16(Suppl 2):A2
management. Again, we have been able to gather most renowned
scientists, neurointensivists and intensivists, emergency physicians, For almost a century, therapeutic hypothermia - or as it was termed in the
cardiologists and other specialists to cover the entire scientific and clinical early days: hibernation - has been discussed as a potential neuroprotective
spectrum of emergency temperature management, technical aspects of measure, in particular in patients suffering from severe intracranial disease
cooling and management of potential complications including shivering, leading to impairment of consciousness, associated with fever [1-3].
but also temperature management in neurology, neurosurgery, intensive In a wide range of diseases, secondary damage to the brain or other
care medicine, in the operation theatre, cardiology, infectious diseases, and organs follows the initial impact and may be responsible for aggravation of
so forth. Beyond that we cross borders and discuss hypothermia and disease condition or clinical state, in particular neurological morbidity and/
intracranial pressure, pharmacodynamics in hypothermic patients and the or mortality [4-11]. Therapeutic hypothermia, recently renamed targeted
influence of hypothermia onto pharmacokinetics/pharmacodynamics, temperature management, including prophylactic normothermia, has been
hypothermia in refractory status epilepticus or heat stroke, hypothermia used to improve this secondary impact onto brain and other organ tissue.
and advanced neuromonitoring, hypothermia and nutrition, shivering and This holds true, in particular, for neurological and neurosurgical intensive
the critical issue of rewarming, amongst other topics. care patients since secondary brain and nervous tissue injury may preclude
The aim of this symposium is to enhance the knowledge on temperature a potentially benign course of disease. The mechanisms of action of
management, increase the readiness and stimulate the preparedness to hypothermia are complex, not yet fully understood. Therapeutic
institute therapeutic hypothermia and/or prophylactic controlled hypothermia/targeted temperature management aims to attenuate a
normothermia, respectively, in patients in need of tissue and organ cascade of secondary injury mechanisms, which is started immediately
© 2012 various authors, licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.Critical Care 2012, Volume 16 Suppl 2 Page 2 of 42
http://ccforum.com/supplements/16/S2
after the initial event (primary injury) and may last for hours and even days substances (for example, prostaglandins). Their balance is essential to
[4,6,12]. The majority of research has focused, so far, on these secondary maintain homeostasis. Ischemic or traumatic conditions may increase
injury processes being destructive to brain and nervous tissue. It may be vasoconstricting substances thus leading to reduced cerebral blood flow.
expected that any such protective effect can be replicated in other organs Whether hypothermia is capable of regulating/improving cerebral
and tissues during therapeutic hypothermia/targeted temperature perfusion is still a matter of investigation, pending the influence of
management. A wide range of side effects may negate and counteract its cerebral autoregulation and the quantity of secreted vasoactive mediators
positive initial effect; this implies side effects of hypothermia per se and in brain-injured patients with cerebral ischemia or any other type of
side effects of rewarming or inconstant maintenance of temperature levels injury [10].
[13-17]. Whether epileptic activity, in particular, subtle nonconvulsive status
This abstract limits itself to potential pathophysiological mechanisms of epilepticus, accepted to indicate severe brain damage, can be positively
actions, the risks of any such mechanism and side effects derived from influenced by therapeutic hypothermia still needs further research.
them [4,5,10,12,16-18]. However, it is accepted that a subtle nonconvulsive status epilepticus
The protective effect of hypothermia may be explained by several pathways. occurring in the acute phase of brain injury is - per se - adding to neuronal
A decreased metabolism with less oxygen and energy consumption and carbon destruction [10,16].
dioxide production may prevent secondary injury when oxygen supply is While many pathophysiological processes and cascades may be influenced
interrupted or, at least, impaired. However, it needs to be stressed that the by targeted temperature management/therapeutic hypothermia and/or even
reduction in metabolic rate, as seen in hypothermia, requires adjustment in prevention of fever through prophylactic normothermia, it is unclear whether
ventilator setup, insulin infusion rate, correct interpretation of electrolytes, in in all types of severely brain-injured patients (for whatever reason) the
particular low phosphate, magnesium and potassium levels. Of particular benefits of this therapeutic hypothermia always outweigh its risks. It is now
interest are the rebound phenomena during rewarming or when, fully ac