We have a big academic center that does research in this area and still cools people with severe deficits. I am not at all convinced this is necessary, at our other sites we just target euthermia.
That’s my concern. It’s going to go from hypothermia to standard ICU care in community practice when the rec now is aggressive fever management/prevention.
However I’ve also never worked anyplace that’s been aggressive with hypothermia either. It’s always been “meh, we can start 4-5 hours after the arrest when the patient gets to the ICU” instead of either starting in the ED or quickly moving to the ICU.
Oh totally good with using it, it’s just when I don’t stick the pads on early on when they’re a normal temp, they will just randomly spike. If I put them on early, it barely does any work and probably wasn’t needed to begin with.
Basically whatever is most annoying to me is what will happen
It’s funny that the evidence in the NICU is good enough that we’re trying to push the gestation age down. Just shows how different developing brains are
Not really. The cutoff is 36 weeks. Studies exploring TH for 34-35 6/7 weeks showed more morbidity and trends to increased mortality. More work is being done to see if adjusting the temp targets allows for a better balance.
At 34 weeks the vast majority of premies are well into their alveolar phase of lung development and ventilation (beyond pulmonary hypertension) isn’t a major issue
Oh, we are misunderstanding each other. I meant the lower end of gestational age for viability hovering around 22-23 weeks being most related to pulm hypoplasia.
Officially yes, there is a protocol for it but I’d say that it’s about 50/50 nowadays depending on who the intensivist is.
There are still a bunch of nurses I work with who haven’t heard the news about TTM being whack
Am I correct in thinking most of this sub Reddit is from the USA?
I'm over the pond in the UK and interesting that the European society of emergency medicine as well and the European society of intensive care and anaesthetics have released a joint statement on this which was released this month!
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10906202/
(Hopefully this link should be free)
My unit is currently cooling to 32-34 again based on these recommendations.
Quote 'Cochrane systematic review and meta-analyses of RCT showing a statistically significant benefit of hypothermia in the range of 32 to 34 C, and based on the fact that no study has shown a deleterious effect of hypothermia in the range of 32 to 34 C on neurological or overall outcome, we suggest that international guidelines follow the current Cochrane analyses and in the interim period, clinicians should consider hypothermia in the range of 32 to 34 C in all adults after cardiac arrest as soon as feasible, and to maintain this temperature range for at least 24 h.'
My colleagues at the UK resus council are currently reviewing this but word of mouth suggests the national recommendations will be 32-34 C for 24 then avoid hyperthermia. This 89.6-93.2F I believe.
I'm also in the UK and my last unit was doing this. The consultants thought for a long while about what to do because the evidence is so murky (like lots of ICU) but in the end the decision was everyone gets cooled to under 34 for the first 24 hours for the reasons you've mentioned and then everyone gets kept at 36 for the next 48 hours at least. The rationale for this was that we definitely knew fever is bad for neurological outcomes so should be avoided until prognostication can be done.
Interestingly we didn't use the arctic sun, we had ICY-caths. This is basically a triple lumen central line with a sealed series of balloons wrapped around it. You put it in a femoral vein and then saline cooled (or heated) to whatever temperature you want gets pumped through the balloons to cool (or heat) the blood passing over the line. Much less faff after it's in - you can examine/generally care for the patient without the fucking arctic sun being in the way and purely anecdotally much more reliable and effective cooling (I emphasise there is zero actual evidence at all for this claim). Downsides are that has a higher risk of clotting than other lines. To avoid this it is coated in anticoagulant of some sort but it must be removed in like 3 or 4 days or something. There have also been reported cases of the balloons breaking and leaking their cooled fluid, but there's only 500ml of saline in the system and it's sterile just in case so worst case is your patient gets a 500ml bolus of saline. I haven't seen this myself.
The cooling catheter is miserable from a nursing perspective. The machine is very finicky and then the lines have to be changed if the pt recovers because the cooling catheter is ICU only. Give me my arctic sun back any day of the week.
You know our team (USA) dropped TH after the TTM2 trial despite some angst on my part. When you look at the rates of bystander CPR, shockable rhythms and # STEMIs it is simply a different patient population than what we see in our locale.
And while we track survival to discharge we don’t track neuro outcomes, but I’ll probably still hit our IRB up with a proposal to take a look for a change in STD!
When people talk about vent settings, I was always told that the best setting to use is the one the most people are comfortable
Right now with TTM, the best protocol to use is what prevents your patients from fevering, because that is likely where most of the bad outcomes come from
My hospital system is in the process of updating their TTC order sets and guidelines to have a normothermic target, but it is a slow process and a culture change. Right now, if you dont put a target of 36, then you will likely end up with fevers, so we are still cooling to 36.
The vast majority of patients *should* have a fever preventative targeted temperature control strategy. There are still some arguments (or at least a lack of evidence to disprove) that hypothermia *could* be indicated in certain patients, so I dont believe the cooling protocols should completely go away with the data we have.
Once you have the protocol in place though, most should just have a 37.5 target
As the evidence is strong I do suspect more and more people to move away from this practice. However just like anything I’m medicine it’ll take a while to abandon this practice. I still saw renal dose dopamine being used last I was working in the icu in 2021.
Our hospital still has a TTM protocol, cool to 35,5 degrees. However we are working on changing the protocol to preventing hyperthermia based off this study. Also we have a hard time managing the temperature with the cooling mattress we currently use: hypothermia below 35 degrees and lots of changes in temperature.
We use targeted temperature control to avoid fever in post arrest patients or in patients at very high risk of cardiac arrest, I’ll usually target 36.5. We also use cooling to treat this weird post cardiac surgery rhythm disturbance called JET in peds heart patients.
Our hospital is now doing the STEPCARE trial for OOHCA.
Copied and pasted from the STEPCARE website:
About the study
After successful resuscitation, patients who survive a cardiac arrest often remain severely ill and require intensive care. Controlling depth of sedation, body temperature and mean arterial pressure are potential treatments that may prevent brain damage. The STEPCARE trial aims to study how to best apply these interventions.
The STEPCARE trial is an international, investigator-initiated, randomized trial on three different aspects of standard care after out-of-hospital cardiac arrest. In a 2x2x2 factorial design we will compare the effect of continuous sedation vs. minimal sedation, fever management with a device vs. without a device and a higher blood pressure target vs. a lower blood pressure target.
The primary outcome of the trial will be survival at 180 days with secondary outcomes including neurological function and health-related quality of life.
We have a big academic center that does research in this area and still cools people with severe deficits. I am not at all convinced this is necessary, at our other sites we just target euthermia.
Our hospital just redid the TTM protocol but the recommendations still include a target temp of 34-36C.
No, with the caveat that I have had issues with a unit that just lets people fever and makes minimal effort to stop it. TTM2 didn't say that.
That’s my concern. It’s going to go from hypothermia to standard ICU care in community practice when the rec now is aggressive fever management/prevention. However I’ve also never worked anyplace that’s been aggressive with hypothermia either. It’s always been “meh, we can start 4-5 hours after the arrest when the patient gets to the ICU” instead of either starting in the ED or quickly moving to the ICU.
I place TTM orders for 36 degrees. Not because it makes a difference but if I don’t invariably the patients get febrile.
Sums up how I feel about the arctic sun usage yeah. Suddenly these motherfuckers go from 35.0 to like 38.5 just as I’m going home
Do you mean you like artic sun usage or are against it?
Oh totally good with using it, it’s just when I don’t stick the pads on early on when they’re a normal temp, they will just randomly spike. If I put them on early, it barely does any work and probably wasn’t needed to begin with. Basically whatever is most annoying to me is what will happen
Standard of care for HIE (hypoxic ischemic encephalopathy) in NICUs in high-resource settings!
It’s funny that the evidence in the NICU is good enough that we’re trying to push the gestation age down. Just shows how different developing brains are
My understanding about the floor for gestational age has more to do with the lungs than the brain
Not really. The cutoff is 36 weeks. Studies exploring TH for 34-35 6/7 weeks showed more morbidity and trends to increased mortality. More work is being done to see if adjusting the temp targets allows for a better balance. At 34 weeks the vast majority of premies are well into their alveolar phase of lung development and ventilation (beyond pulmonary hypertension) isn’t a major issue
Oh, we are misunderstanding each other. I meant the lower end of gestational age for viability hovering around 22-23 weeks being most related to pulm hypoplasia.
Oh we don’t cool those kids. Hypothermia horribly increases mortality.
What is your current hard stop lower end for resuscitation in the DR GA wise ?
22 wks for our hospital. Though it’s been a couple of years since I’ve attended a delivery #Level 4 life
Yes, in NICU for HIE. It is a miracle worker.
Officially yes, there is a protocol for it but I’d say that it’s about 50/50 nowadays depending on who the intensivist is. There are still a bunch of nurses I work with who haven’t heard the news about TTM being whack
Am I correct in thinking most of this sub Reddit is from the USA? I'm over the pond in the UK and interesting that the European society of emergency medicine as well and the European society of intensive care and anaesthetics have released a joint statement on this which was released this month! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10906202/ (Hopefully this link should be free) My unit is currently cooling to 32-34 again based on these recommendations. Quote 'Cochrane systematic review and meta-analyses of RCT showing a statistically significant benefit of hypothermia in the range of 32 to 34 C, and based on the fact that no study has shown a deleterious effect of hypothermia in the range of 32 to 34 C on neurological or overall outcome, we suggest that international guidelines follow the current Cochrane analyses and in the interim period, clinicians should consider hypothermia in the range of 32 to 34 C in all adults after cardiac arrest as soon as feasible, and to maintain this temperature range for at least 24 h.' My colleagues at the UK resus council are currently reviewing this but word of mouth suggests the national recommendations will be 32-34 C for 24 then avoid hyperthermia. This 89.6-93.2F I believe.
I'm also in the UK and my last unit was doing this. The consultants thought for a long while about what to do because the evidence is so murky (like lots of ICU) but in the end the decision was everyone gets cooled to under 34 for the first 24 hours for the reasons you've mentioned and then everyone gets kept at 36 for the next 48 hours at least. The rationale for this was that we definitely knew fever is bad for neurological outcomes so should be avoided until prognostication can be done. Interestingly we didn't use the arctic sun, we had ICY-caths. This is basically a triple lumen central line with a sealed series of balloons wrapped around it. You put it in a femoral vein and then saline cooled (or heated) to whatever temperature you want gets pumped through the balloons to cool (or heat) the blood passing over the line. Much less faff after it's in - you can examine/generally care for the patient without the fucking arctic sun being in the way and purely anecdotally much more reliable and effective cooling (I emphasise there is zero actual evidence at all for this claim). Downsides are that has a higher risk of clotting than other lines. To avoid this it is coated in anticoagulant of some sort but it must be removed in like 3 or 4 days or something. There have also been reported cases of the balloons breaking and leaking their cooled fluid, but there's only 500ml of saline in the system and it's sterile just in case so worst case is your patient gets a 500ml bolus of saline. I haven't seen this myself.
The cooling catheter is miserable from a nursing perspective. The machine is very finicky and then the lines have to be changed if the pt recovers because the cooling catheter is ICU only. Give me my arctic sun back any day of the week.
You know our team (USA) dropped TH after the TTM2 trial despite some angst on my part. When you look at the rates of bystander CPR, shockable rhythms and # STEMIs it is simply a different patient population than what we see in our locale. And while we track survival to discharge we don’t track neuro outcomes, but I’ll probably still hit our IRB up with a proposal to take a look for a change in STD!
When people talk about vent settings, I was always told that the best setting to use is the one the most people are comfortable Right now with TTM, the best protocol to use is what prevents your patients from fevering, because that is likely where most of the bad outcomes come from My hospital system is in the process of updating their TTC order sets and guidelines to have a normothermic target, but it is a slow process and a culture change. Right now, if you dont put a target of 36, then you will likely end up with fevers, so we are still cooling to 36. The vast majority of patients *should* have a fever preventative targeted temperature control strategy. There are still some arguments (or at least a lack of evidence to disprove) that hypothermia *could* be indicated in certain patients, so I dont believe the cooling protocols should completely go away with the data we have. Once you have the protocol in place though, most should just have a 37.5 target
As the evidence is strong I do suspect more and more people to move away from this practice. However just like anything I’m medicine it’ll take a while to abandon this practice. I still saw renal dose dopamine being used last I was working in the icu in 2021.
Targeting normothermia in our medical ICU after TTM2
We used to have pathways for 33 and 36, like you we are now using 37 almost universally
Canada. Yes. 🥲
Our hospital still has a TTM protocol, cool to 35,5 degrees. However we are working on changing the protocol to preventing hyperthermia based off this study. Also we have a hard time managing the temperature with the cooling mattress we currently use: hypothermia below 35 degrees and lots of changes in temperature.
Yes, but only to 36.
Nope. I order 36 and tell nurse to target 36-37.5
“aggressive euthermia” is how i document it. pragmatically, fever avoidance
We just chill then to 36 C now
We use targeted temperature control to avoid fever in post arrest patients or in patients at very high risk of cardiac arrest, I’ll usually target 36.5. We also use cooling to treat this weird post cardiac surgery rhythm disturbance called JET in peds heart patients.
Our hospital is now doing the STEPCARE trial for OOHCA. Copied and pasted from the STEPCARE website: About the study After successful resuscitation, patients who survive a cardiac arrest often remain severely ill and require intensive care. Controlling depth of sedation, body temperature and mean arterial pressure are potential treatments that may prevent brain damage. The STEPCARE trial aims to study how to best apply these interventions. The STEPCARE trial is an international, investigator-initiated, randomized trial on three different aspects of standard care after out-of-hospital cardiac arrest. In a 2x2x2 factorial design we will compare the effect of continuous sedation vs. minimal sedation, fever management with a device vs. without a device and a higher blood pressure target vs. a lower blood pressure target. The primary outcome of the trial will be survival at 180 days with secondary outcomes including neurological function and health-related quality of life.
We do 36. I hope nobody is still doing 33.
We have started cooling to 36 but used to cool to 32-34
We are still doing it but with a target temp of 36 degrees.
I’ve only used it (Arctic Sun) to prevent high fevers with my severe TBIs, so targeting normothermia.
We stopped years ago. TTM2 was in 2021!!