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.
- TBI and SAH patients with a GCS 8 or less with a temperature >38 C.
- Intubated and on a ventilator.
- ICP monitoring.
- 2 temperature measurement sources needed
- Foley temp probe is required (FYI not MRI compatible).
- Select one of the following
- 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.
- 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.
- 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.
- 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
|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.|