Treatment of fever in the neurologic intensive care unit with a catheter-based heat exchange system

ContextElevated temperature worsens injury in experimental focal and global ischemia and brain trauma. Fever is common in patients with acute neurologic illness and independently predicts poor outcome. Conventional means of treating fever are not very effective in this population. ObjectiveTo study the effectiveness of a catheter-based heat exchange system in reducing elevated temperatures in critically ill neurologic and neurosurgical patients. Design, Intervention, Setting, and PopulationThis was a prospective randomized, nonblinded trial that compared conventional treatment of fever (acetaminophen and cooling blankets) with conventional treatment plus an intravascular catheter-based heat exchange system (Alsius, Irvine, CA). Patients admitted to one of 13 neurologic intensive care units in academic medical centers were eligible if they a) suffered subarachnoid hemorrhage, intracerebral hemorrhage, ischemic infarction, or traumatic brain injury; b) had a temperature >38°C on two occasions or for >4 continuous hrs; and c) required central venous access. Main Outcome MeasureThe fever burden (area under the curve >38°C) for 72 hrs was compared in an intention to treat analysis. Safety of the catheter system was monitored. ResultsA total of 296 patients were enrolled over 20 months. Forty-one percent had subarachnoid hemorrhage, 24% had traumatic brain injury, 23% had intracerebral hemorrhage, and 13% had ischemic stroke. The groups were matched in terms of age, body mass index, sex, and Glasgow Coma Scale score distribution. Fever burden was 7.92 vs. 2.87°C-hrs in the conventional group and catheter groups, respectively (64% reduction, p < .01). There was no higher rate of infection or the use of sedatives, narcotics, or antibiotics in the catheter group. The catheter did not significantly increase risk to the patient beyond that of a central catheter. ConclusionsThe addition of this catheter-based cooling system to conventional management significantly improves fever reduction in neurologic intensive care unit patients.

[1]  F. Buonanno,et al.  Fever in subarachnoid hemorrhage , 2001, Neurology.

[2]  A. Bjorksten,et al.  The effects of physical treatment on induced fever in humans. , 1999, The American journal of medicine.

[3]  A. Térent,et al.  The prognosis for patients with cerebrovascular stroke and transient ischemic attacks. , 1981, Upsala journal of medical sciences.

[4]  A. Roberts,et al.  Quality improvement guidelines for central venous access. The Standards of Practice Committee of the Society of Cardiovascular & Interventional Radiology. , 1997, Journal of vascular and interventional radiology : JVIR.

[5]  P. Walson,et al.  Ibuprofen, acetaminophen, and placebo treatment of febrile children , 1989, Clinical pharmacology and therapeutics.

[6]  I. König,et al.  Predicting functional outcome and survival after acute ischemic stroke , 2002, Journal of Neurology.

[7]  B. Hindfelt.  THE PROGNOSTIC SIGNIFICANCE of SUBFEBRILITY and FEVER IN ISCHAEMIC CEREBRAL INFARCTION , 1976, Acta neurologica Scandinavica.

[8]  B. Siesjö,et al.  The effect of mild hyperthermia and hypothermia on brain damage following 5, 10, and 15 minutes of forebrain ischemia , 1990, Annals of neurology.

[9]  A. Roberts,et al.  Quality improvement guidelines for central venous access. The Standards of Practice Committee of the Society of Cardiovascular & Interventional Radiology. , 1997, Journal of vascular and interventional radiology : JVIR.

[10]  H. Slyter.  Guidelines for the management of patients with acute ischemic stroke. , 1995, Stroke.

[11]  R. Chesnut.  Guidelines for the management of severe head injury. Introduction. , 1997, Journal of neurotrauma.

[12]  R. DʼAlessandro,et al.  Fever in acute stroke worsens prognosis. A prospective study. , 1996, Stroke.

[13]  B. Scheithauer,et al.  Temperature changes of > or = 1 degree C alter functional neurologic outcome and histopathology in a canine model of complete cerebral ischemia. , 1995, Anesthesiology.

[14]  M D Ginsberg,et al.  Effect of mild hypothermia on ischemia-induced release of neurotransmitters and free fatty acids in rat brain. , 1989, Stroke.

[15]  S. Schwab,et al.  Endovascular Cooling for Moderate Hypothermia in Patients With Acute Stroke: First Results of a Novel Approach , 2001, Stroke.

[16]  B. Scheithauer,et al.  Temperature Changes of greater or equal to 1 degree Celsius Alter Functional Neurologic Outcome and Histopathology in a Canine Model of Complete Cerebral Ischemia , 1995 .

[17]  R. Steele,et al.  Evaluation of sponging and of oral antipyretic therapy to reduce fever. , 1970, The Journal of pediatrics.

[18]  L. Kappelle,et al.  Effect of Paracetamol (Acetaminophen) on Body Temperature in Acute Ischemic Stroke: A Double-Blind, Randomized Phase II Clinical Trial , 2001, Stroke.

[19]  Guo-yi Gao,et al.  Early indicators of prognosis in 846 cases of severe traumatic brain injury. , 2002, Journal of neurotrauma.

[20]  P. Andrews,et al.  Management of hyperthermia in traumatic brain injury , 2002, Current opinion in critical care.

[21]  R. Vargas,et al.  Evaluation of the Antipyretic Effect of Ketorolac, Acetaminophen, and Placebo in Endotoxin‐Induced Fever , 1994, Journal of clinical pharmacology.

[22]  D. Marion,et al.  Guidelines for the management of severe head injury. Brain Trauma Foundation. , 1996, European journal of emergency medicine : official journal of the European Society for Emergency Medicine.

[23]  T. Olsen,et al.  Body temperature in acute stroke: relation to stroke severity, infarct size, mortality, and outcome , 1996, The Lancet.

[24]  S. Mayer,et al.  Clinical trial of an air-circulating cooling blanket for fever control in critically ill neurologic patients , 2001, Neurology.

[25]  J M Zabramski,et al.  Guidelines for the management of spontaneous intracerebral hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. , 1999, Stroke.

[26]  R. Busto,et al.  Delayed posttraumatic brain hyperthermia worsens outcome after fluid percussion brain injury: a light and electron microscopic study in rats. , 1996, Neurosurgery.

[27]  J. Grotta,et al.  Guidelines for the Management of Patients With Acute Ischemic Stroke A Statement for Healthcare Professionals , 2005 .

[28]  R. Busto,et al.  Combating hyperthermia in acute stroke: a significant clinical concern. , 1998, Stroke.

[29]  M. Diringer,et al.  Factors associated with withdrawal of mechanical ventilation in a neurology/neurosurgery intensive care unit , 2001, Critical care medicine.

[30]  W. Thies,et al.  Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. , 1994, Stroke.

[31]  D. Marion,et al.  Hyperthermia in the Neurosurgical Intensive Care Unit , 2000, Neurosurgery.

[32]  S Senn,et al.  Analysis of serial measurements in medical research. , 1990, BMJ.