Hypothermia improves outcome from traumatic brain injury.
Hypothermia for patients with severe traumatic brain injury (TBI) remains controversial despite a strong biological rationale and reasonable evidence from the literature. The "negative" Clifton study seems to have reduced enthusiasm for hypothermia, however the aim of this review is to analyse the evidence from all randomised controlled trials (RCT) and meta-analyses on this topic to determine whether there is adequate support for the view that hypothermia does improve outcome from TBI. The biological rationale for hypothermia is supported by animal and human mechanistic studies of TBI and human clinical studies of brain injury caused by out-of-hospital cardiac arrest. Several small single-centre RCT's have demonstrated that hypothermia leads to both improved survival and improved favourable neurological outcome in TBI. The Clifton study, which was larger and multi-centre, found hypothermia had no major benefits in TBI, although this study can be criticised for several issues of trial methodology (trial design and application of the intervention) and group comparison. Several meta-analyses have given slightly discordant results, but the two most recent meta-analyses agree that hypothermia improves favourable neurological outcome and probably survival. Subsequent to these meta-analyses, a RCT was published which has confirmed that hypothermia is beneficial in a large group of TBI patients. When the published evidence is considered in total, even if hypothermia can't be justified in all TBI patients, if it is applied optimally in the most appropriate patients, hypothermia certainly improves outcome from TBI. If hypothermia is correctly applied (early, long and cool enough) in the optimal group of TBI patients (young with elevated ICP), there seems to be no doubt that hypothermia is effective in improving both survival and favourable neurological outcome from TBI.
Department of Intensive Care, The Alfred Hospital, Melbourne, VIC 3004, Australia.
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Davies