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Therapeutic Hypothermia

Therapeutic Hypothermia. Bryan Sloane. What is it?. A lowering of the core body temperature for medical benefits. Normal Body Temperature = 37°C Therapeutic hypothermia range = 32-34°C Bladder Temp. Why use it?. Neuroprotective effects

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Therapeutic Hypothermia

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  1. Therapeutic Hypothermia Bryan Sloane

  2. What is it? • A lowering of the core body temperature for medical benefits. • Normal Body Temperature = 37°C • Therapeutic hypothermia range = 32-34°C • Bladder Temp.

  3. Why use it? • Neuroprotective effects • Down regulate the negative aspects of the immune response following traumatic injury to the CNS. • Peripheral Tissue Preservation following amputation • Protective effects on the CNS following hypoxia

  4. History of Therapeutic Hypothermia • In 1800’s Russia, patients in arrest would be covered in snow with the hopes of a return of spont. circulation. • Napoleon’s forces used it for the preservation of amputated limbs as well as an anesthetic • In 1937 Fay cooled a pt. to 32° C to prevent cancer cells from spreading • By 1959 it was being used for CNS injury as well as in aneurysm repair.

  5. Modern Uses • The American Heart Association and European Resuscitation Council have recommended induced hypothermia in patients who have a return of spontaneous circulation after an out of hospital cardiac arrest. • This decision was based on two trials from 2002 which showed significant neurological protection following anoxic brain injury • 275 pts. Hypothermia group had 55% favorable outcome vs 39% in nonthermic (Holzer [Eur] and Benard [Aus])

  6. CNS injury • Fig. 2. Spinal cord injury: hematoma (H) with shift and compression of the spinal cord (M; Dr. Bodo Kress) • Damage can come from inflammatory responses, hemorrhage, or hypoxia

  7. What is the immune response and how does it hurt? • Immune responses are triggered by injury and involved leukocytes and chemical signals such as chemokines and complement • Cytokines regulate the process by signaling the release of other factors and recruiting different leukocytes • Very regulated process, but dangerous in the CNS because it is delayed compared to peripheral tissue and due to the specialized cells found only in the CNS

  8. What does it do/hurt cont. • The injury induced inflammation is though to directly effect some of the neuropathology and necrosis that exists after CNS injury. (unique 2° necrosis) • Associated Cytokines may be neurotoxic via induction of reactive oxygen species • Tumor Necrosis Factor-alpha is also released. It is cytotoxic to some neuronal cells and neuroprotective for others.

  9. One more immuno slide…… • Nitric oxide mediated damage • Also protective and destructive, depending on the timing • Plays a role in the generation of VERY toxic free radicals that destroy lipids through peroxidation • NO has been shown to contribute to cell death after CNS injury.

  10. So where does hypothermia come in? • Mild hypothermia has been shown to protect neurological tissue following injury. • Reduces metabolic rate in hypoxic injury and has a huge effect in slowing the immune response. • It has been shown that it can reduce leukocyte rolling and adhesion (key part in immune response)

  11. How can we be sure? • Dimar, et al. 2000 • Study using rat models of CNS injury • Used acute stenosis of the Spinal Cord as well as severe contusion • Directly applied a cooling factor to the injured region of the Cord • Showed that rats who were treated with directly applied hypothermia had a significant increase in recovery

  12. Has it been used clinically? • YES, for many things • 1 famous prehospital application • Buffalo Bills tight end Kevin Everett 2007 • fracture dislocation of C3-C4 • No sensation below the neck • COMPLETE RETURN OF MOTOR FUNCTION following induced hypothermia!!!!

  13. Sources • Bernhard, Michael, Andre Gries, Paul Kremer, and Bernd W. Bottiger. "Spinal Cord Injury (SCI)----Prehospital Managment." Resuscitation 66 (2005): 127-39. • Dimar, John, Christopher Shields, Yi P. Zhang, Darlene A. Burke, George H. Raque, and Steven D. Glassman. "The Role of Directly Applied Hypothermia in Spinal Cord Injury." SPINE 25 (2000): 2294-302. • Alzaga, Ana G., Mario Cerdan, and Joseph Varon. "Therapeutic Hypothermia." Resuscitation 70 (2006): 369-80.

  14. Sources Cont. • Behtea, John R., and Dalton W. Dietrich. "Targeting the host inflammatory response in traumatic spinal cord injury." Current Opinion in Neurology 15 (2002): 355-60. • Suprun, Christopher. "The Cold Truth about Spinal Injury." Journal of Emergency Medical Services 16 Nov. 2007. • Cappuccino, Andrew. "Moderate Hypothermia as Treatment for Spinal Cord Injury." ORTHOPEDICS 31 (2008): 243.

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