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Targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke

Updated consensus guideline recommendations by the Neuroprotective Therapy Consensus Review (NTCR) group

British Journal of Anaesthesia

Submitted September 2023 by Dr Megan Wellbeloved

Read by 166 Journal Watch subscribers

This is an updated guideline on targeted temperature management in adult patients in the critical care setting with intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH) or acute ischaemic stroke (AIS). This was developed using the Delphi method consisting of 19 panel members (all experts in the management of ICH, SAH and AIS). A survey was developed using recommendations from previously published guideline in 2018. These were then reviewed in three rounds: online survey, face-to-face meeting and post meeting reviews. Recommendations were made based on a cut off level of agreement of 80% of the panel.

Take home messages/commentary:
Recommendations for TTM in adult patients with ICH, SAH and AIS:
• Temperature should be measured continuously or hourly (4 hourly if not ventilated with AIS)
• An automated feedback-controlled device is recommended to treat neurogenic fever
• Temperature should be controlled for as long as there is a risk of secondary brain injury (determined clinically, with neuroimaging and monitoring)
• Core temperature (bladder and oesophageal) measurement is recommended (Tympanic membrane in non-ventilated patients)
• Recommended target temperature is 36.0 °C – 37.5 °C
• Maximum temperature variation should be < +/- 0.5 °C per hour and < 1 °C per 24 hours
• Neurogenic fever can adversely affect outcomes and TTM should be started at 37.5 °C
• It is important to distinguish between neurogenic fever and other causes of fever, and TTM may mask worsening infection
• Shivering should also be managed in this patient group. A step wise approach should be used with various agents as well as controlled warming < 1 °C per 24 hours
• This guideline has been developed for a specific patient group: adults with ICH, SAH and AIS in the critical care environment. These recommendations may not be applicable to the paediatric population or adults outside critical care (where the recommendations may be difficult to achieve).
• Limitations include those of the Delphi method itself as well as potential bias of the panel from neuro critical care in high resource setting. These recommendations may not be appropriate in other settings.
• No consensus obtained for:
o Which first line agent should be used to manage shivering
o Which metric should be used to measure quality of TTM

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