Normothermia for Neuro-protection
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NICU Guidelines for Normothermia
Goal
To induce normothermia in patients who are refractory to conventional fever treatment.
Patient eligibility
- Presence of fever (T >= 38°C or 101°F by reliable and reproduced means, including superficial artery temporal artery probe, continuously bladder temperature measurement or rectal thermometry), that is refractory to initial therapy with acetaminophen 650 mg, cooling blankets, and ice packs. Refractory status is determined by a lack of temperature reduction within 2 hours of these interventions.
- Patient must undergo an appropriate infectious disease work-up and anti-microbial therapy initiated if indicated.
- Alternative sources of fever should be investigated as appropriate, including lines/catheters, medications, deep venous thrombosis, cholecystitis, pancreatitis, sinusitis, etc.
- Patients not to be considered for induced normothermia:
- Contraindications to induced temperature reduction, such as patients with known hematological dyscrasias which affect thrombosis, (cryoglobulinemia, sickle cell disease, serum cold agglutinins), or known deep venous thrombosis (for femoral catheter approach only)
- Peripheral vasospastic disorders
- Contraindication for central venous catheter placement (for catheter-based approach only)
- Known or suspected diagnosis of heparin induced thrombocytopenia (for catheter-based approach only).
- Extensive skin defects (for cooling vest approach only)
- Diagnosis of sepsis syndrome
Procedure
All patients with refractory fever will be identified and a bladder temperature probe will be placed. Target temperature for normothermia will be 37.0 ± 0.5°C (97.7-99.5°F). Ventilator warming device temperatures will be maintained at ≤ 37°C. Tylenol will be administered 650 mg q6h for 72 hours.
Surveillance cultures from blood, urine, sputum, stool, and CSF (if applicable) will be sent if a significant rise in the WBC count is detected during the period of induced normothermia. A rise in the WBC count by ≥ 20% from the time of initiation of induced normothermia is considered significant. As part of routine care in the NICU, additional cultures will be sent on a q72 hour schedule if an infectious source is suspected but not identified. The need for additional cultures prior to 72 hours is left to the discretion of the treating intensivist.
Normothermia will be maintained continuously for a period of 72 hours with either a catheter-based system or surface cooling vest, at which time the need for ongoing temperature control will be reassessed. Should the patient subsequently develop a refractory fever over the next 24 hours, re-induction of normothermia will be considered and left to the discretion of the attending neurointensivist. Shivering may be encountered while maintaining normothermia. The treatment should include the use of meperidine boluses and/or oral buspirone in patients in whom a mild degree of sedation is considered acceptable.
Meperidine:
- 12.5-50 mg INTRAVENOUSLY 3-4 times a day or as a continuous infusion for up to 24 hours as needed. NOT TO BE USED IN PATIENTS WITH DOCUMENTED RENAL INSUFFICIENCY (serum creatinine ≥ 1.5). CONTRAINDICATED WITH CONCOMITINANT USE OF MONOAMINE OXIDASE INHIBITORS (WITHIN 2 WEEKS).
Buspirone:
- 5 mg ORALLY 2-3 times a day OR 7.5 mg ORALLY twice a day; may increase the dosage by 5 mg/day every 2-3 days as needed (usual dose 20-30 mg/day 2-3 divided doses, MAX dose 60 mg/day)
Dexmedetomidine:
- May be used only with approval in specific units. Please contact the Neuro ICU staff regarding it's use in specific instances (726-8071).
Authoring Information
Reviewed/Approved by: David M. Greer, M.D.
Last updated: 7/25/2007