Normothermia Protocol for TBI and SAH

The evidence is accumulating that hyperthermia following severe traumatic brain injury (TBI) occurs frequently and worsens neurological outcomes. An interesting paper, Neurocrit Care. 2009;11(1):82-7, showed improved neurological incomes in patients who maintained normothermia. Based on this, our institution has developed a protocol for use in our neurocritical care patients to maintain normothermia.

Inclusion

  • TBI and SAH patients with a GCS 8 or less with a temperature >38 C.
  • Intubated and on a ventilator.
  • ICP monitoring.

Initiate

  • 2 temperature measurement sources needed
    • Foley temp probe is required (FYI not MRI compatible).
    • Select one of the following
      • Rectal
      • Esophageal temperature probe (can be passed nasally on trached patients).
      • Swan-Ganz catheter
  • Alsius catheter to be placed by critical care fellow or Arctic sun pads placed by bedside RN.
  • Start shiver prevention protocol.
  • Foley temp connected to the machine. Second source to the bedside monitor. Set appropriate monitor alarm limits. Alarms should not be turned off.
  • Set machine temp to 36.5 C.
  • Cultures if needed will be determined by critical care service.
    • If blood cultures ordered, both need to be peripheral sticks. Do not draw off lines.

Shiver Prevention

  • Counter rewarm with forced warm air. Bair hugger blanker 40-43 C to be on at all times.
  • Maintain a normal room temperature. Do not purposely cool the room.
  • Magnesium gtt. Give 2-4g IV over 30-60 min. Then start a magnesium gtt at 1g/hr. Goal magnesium level 3-4 mg/dL. Increase gtt 25% if magnesium level <4mg/dL. For magnesium level >6mg/dL stop gtt and recheck. Check magnesium levels Q2H until magnesium level is <5mg/dL. Then restart gtt at 75% of previous rate.
  • Acetaminophen 650 mg Q4hour scheduled. If acetaminophen causes CPP < 60 or MAP <60 discontinue scheduled acetaminophen.

Shiver Management Medication

  • Medication management is dependent on bedside shivering scores. See table below for when to implement.
  • Buspar 15-30 mg Q8H scheduled.
  • Fentanyl 25-50 mcg IV Q15min PRN for shiver.
  • Meperidine 25-50mg IV Q30min PRN for shiver.

Maintaining

  • Measure magnesium levels Q6hours. Once level stays consistent it may switch to Q24hours.
  • Hepatic panel to be measured every Monday and Thursday.
  • Document Q1H temperatures and PRN.
  • Document Q1H water bath temperatures.
  • Complete skin assessment Q8hours.
  • Assess and document the patient’s Bedside Shivering Assessment score Q1hour. Goal is <=1.
    • Check masseter, pectoralis, deltoids, and quadriceps muscles.
    • 0 = No shivering is detected on palpation of the masseter, neck, or chest muscles.
    • 1 = Shivering localized to the neck and thorax only.
    • 2 = Shivering involves gross motor movement of the upper extremities (in addition to the neck and thorax.
    • 3 = Shivering involves gross movements of the trunk and upper and lower extremities.

Discontinuation

  • If unable to control shivering stop normothermia protocol.
  • Maintain for TBI pt during acute phase (avg 7 days). Daily check with Neurosurgery to discontinue.
  • Maintain for SAH pt during acute phase (avg 2 weeks). Daily check with Neurosurgery to discontinue.
  • Arctic Sun pads to be changed every 5 days. Will loose adhesive quality over time.
  • Remove Alsius catheter or Arctic sun pads when normothermia order discontinued.
  • Stop shiver prevention/maganeemnt medications when normothermia order discontinued.

Sivering Management Table

Score Shivering Status Description Action
0 None No shivering is detected on palpation of the masseter, neck or chest muscle. Continue counter rewarm. Mag gtt goal 3-4. Acetaminophen 650mg Q4h.
1 Mild Shivering localized to the neck and thorax only. Monitor BSAS score closely. Give fentanyl and add Buspar 15mg Q8H.
2 Moderate Shivering involves gross motor movement of the upper extremities (in addition to neck & thorax). Escalate anti-shivering intervention to maintain BSAS score <=1. Give fentanyl and increase buspar to 30mg Q8H and give magnesium 2g over 30 minutes and increase magnesium gtt goal to 4-5. Give meperidine if needed.
3 Severe Shivering involves gross movements of the trunk and upper and lower extremities Bolus sedation and escalate anti-shivering intervention to maintain BSAS score <=1. Give meperidine and speak to PharmD for further interventions.
2016-10-13T18:16:33+00:00 July 12th, 2013|Trauma|

About the Author:

Cardiac Intensivist, Resuscitationist, Emergentologist. Educator. Doodler. Friend. Most importantly, husband to my wife & superhero to my son.

5 Comments

  1. Scott July 13, 2013 at 1:55 am - Reply

    very nice job with this

  2. Taylor July 14, 2013 at 1:50 am - Reply

    Core brain temperature can be several degrees higher than measured peripheral/esophageal temperature so even a “normothermic” patient could have a hyperthermic brain. A Licox monitor can give you better brain temperature readings, if you are looking to monitor ICP as well.

  3. Volker July 15, 2013 at 1:55 pm - Reply

    Excellent approach. Actually i have never read such a consistent mg2+ planning.

  4. rfdsdoc July 19, 2013 at 3:48 am - Reply

    Hi
    thankyou!
    just one possible correction. in the shiver prevention section, the dose of magnesium is given in mg.
    I assume its supposed to be gm?
    Minh Le Cong

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