Table 5.
Summary of the best evidence on target temperature management practices for neurocritical illness.
| Theme of evidence | Content of evidence | Level of recommendation |
|---|---|---|
| Preparation | 1. Invasive blood pressure monitoring should be continued, hemodynamic stability should be stabilized, or low-dose vasoactive drugs should be given to maintain blood pressure (19) | B |
| 2. Establish effective central venous access (36) | B | |
| 3. Establish an artificial airway and provide mechanically assisted ventilation (23) | B | |
| 4. It is recommended to place a nasogastric tube or nasoenteric tube (28) | A | |
| 5. Before starting TTM, analgesic and sedative drugs should be used to prevent chills, but the patient’s cough and spontaneous breathing should be preserved, and the Richmond agitation-sedation score was −4 point (6) | A | |
| 6. It is recommended that patients treated with TTM continuously monitor their core body temperature, and based on the advantages of non-invasive and easy operation, esophageal temperature is the first choice, followed by bladder temperature, and body surface temperature can be monitored when implementing normal body temperature control (32) | A | |
| 7. Cooling equipment: Preferential selection of new body surface cooling technology with temperature feedback control device or intravascular cooling technology for TTM. If you do not have the conditions, you can also choose traditional body surface cooling techniques (ordinary ice blankets, ice caps, ice packs) for cooling, but you need to monitor the core temperature more closely (28) | A | |
| Induction | 8. With the goal of maintaining a normal body temperature (36–37 °C), actively prevent fever (≤37.5 °C) (24, 31). For patients with refractory increased ICP, maintaining the core temperature at 32 to 35 °C may be considered (31) | A |
| 9. Target temperature maintenance time: 24–72 h for patients with acute ischemic stroke and large-scale cerebral infarction, and 3–5 days for patients with hemorrhagic stroke (28). Patients with refractory increased ICP may consider long-term mild hypothermia treatment (for more than 5 days) (31) | A | |
| 10. Patients with acute head injury, ischemic stroke and hemorrhagic stroke should start TTM treatment as soon as possible (6–72 h) (7, 8, 19). For patients with traumatic brain injury, the primary goal in the initial management is the prevention of fever and maintenance of normothermia (31) | A | |
| Maintenance | 11. Real-time monitoring of vital signs, measurement of central venous pressure, intracranial pressure, cerebral perfusion pressure, skin temperature, core temperature (esophagus, bladder or rectum), and observation of pupil changes (8, 34) | B |
| 12. Monitor blood gas analysis every 1–2 h, and adjust the target pH value to be 7.35–7.45, arterial carbon dioxide partial pressure to be 35–40 mmHg, arterial blood oxygen partial pressure to be 80-120 mmHg, and potassium ion concentration to be 3.5–5.3 mmol/L (8, 9) | B | |
| 13. Maintain blood glucose level at 7.8–10.0 mmol/L (adjust the frequency of blood glucose testing according to blood glucose level) (7, 25) | B | |
| 14. Regular review of cranial CT, regular neurological examination, continuous or intermittent EEG, cerebral oxygen and cerebral blood flow monitoring (28, 29) | B | |
| 15. It is recommended to use electromyography to continuously monitor the occurrence of chills, and the severity of chills can also be assessed using the chills assessment scale (19, 32) | A | |
| 16. Enteral nutrition should be started at a low rate early (within 24–48 h after entering the intensive care unit), and the feeding rate should be adjusted according to the gastrointestinal situation (27, 36) | B | |
| 17. When enteral nutrition exceeds the 7-day energy target and cannot be reached (< 60% energy target), parenteral nutrition supplementation is recommended (10) | B | |
| 18. Nasogastric tube feeding is preferred for enteral nutrition, and post-pyloric feeding can be used for patients who are intolerant to nasogastric tube feeding and have a high risk of aspiration (23, 25) | A | |
| 19. Low-dose (75%) enteral nutrition can be given during hypothermia treatment, and the dose can be gradually increased after rewarming (28, 33) | B | |
| Complication management | 20. It is recommended to monitor intra-abdominal pressure (IAP) and gastric residual volume (GRV) every 4–6 h. When the IAP is 12–15 mmHg, routine enteral nutrition can be continued; When the IAP is 16–20 mmHg, low-speed nourishing feeding should be used. When the IAP >20 mmHg, enteral nutrition should be suspended. Low-speed enteral feeds can be given when the GRV exceeds 200 mL, and enteral nutrition should be suspended when the GRV >500 mL (19, 26) | A |
| 21. During the implementation of enteral nutrition, gastrointestinal motility drugs, laxatives or enemas can be given, abdominal insulation can be given, and if necessary, the rehabilitation department can be asked to implement gastrointestinal electrical stimulation (30, 32, 33) | B | |
| 22. Strengthen the monitoring of arrhythmias, such as sinus bradycardia, ventricular tachycardia, atrial fibrillation, ventricular fibrillation, and QT interval prolongation (8, 32) | A | |
| Rewarming | 23. It is recommended to control the rewarming of patients treated with TTM, and the rate of rewarming is 0.25–0.5°C/h (7, 27) | A |
| 24. After rewarming, the core body temperature should be controlled below 37.5 °C and maintained at least 72 h after resuscitation (19, 29) | A | |
| 25. In the rewarming stage, the frequency of blood gas analysis and electrolyte examination is once every 2–4 h (6, 8) | B | |
| Prognostic management | 26. Patients with severe neurological illness are recommended to use the Glasgow Coma Scale (GCS), activities of daily living (Barthel index), modified Rankin scale, and National Institutes of Health Stroke Scale (NIHSS) to assess neurological prognosis after 6 months to guide treatment strategies. Furthermore, the Montreal Cognitive Assessment (MoCA) is recommended for evaluating long-term cognitive function, and the SF-36 (Medical Outcomes Study 36-Item Short-Form Health Survey) quality of life scale is suggested for assessing patients’ overall quality of life (28, 29, 35) | A |
| 27. It is recommended to follow up the short-term (≤1 month) and long-term (≥3 months) mortality rate of patients to evaluate the efficacy of TTM (7, 19) | B |
TTM, targeted temperature management; EEG, electroencephalography; IAP, intra-abdominal pressure; GRV, gastric residual volume; GCS, Glasgow Coma Scale; NIHSS, National Institutes of Health Stroke Scale; MoCA, Montreal Cognitive Assessment; SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey.