Clinical applications of targeted temperature management.
Targeted temperature management (TTM) has been investigated experimentally and used clinically for over 100 years. The initial rationale for the clinical application of TTM, historically referred to as therapeutic hypothermia, was to decrease the metabolic rate, allowing the injured brain time to heal. Subsequent research demonstrated the temperature dependence of diverse cellular mechanisms including endothelial dysfunction, production of reactive oxygen species, and apoptosis. Consequently, modern use of TTM centers on neuroprotection following focal or global neurologic injury. Despite a solid basic science rationale for applying TTM in a variety of disease processes, including cardiac arrest, traumatic brain injury, ischemic stroke, neonatal ischemic encephalopathy, sepsis-induced encephalopathy, and hepatic encephalopathy, human efficacy data are limited and vary greatly from disease to disease. Ten years ago, two landmark investigations yielded high-quality data supporting the application of TTM in comatose survivors of out-of-hospital cardiac arrest. Additionally, TTM has been demonstrated to improve outcomes for neonatal patients with anoxic brain injury secondary to hypoxic ischemic encephalopathy. Trials are currently under way, or have yielded conflicting results in, examining the utility of TTM for the treatment of ischemic stroke, traumatic brain injury, and acute myocardial infarction. In this review, we place TTM in historic context, discuss the pathophysiologic rationale for its use, review the general concept of a TTM protocol for the management of brain injury, address some of the common side effects encountered when lowering human body temperature, and examine the data for its use in diverse disease conditions with in-depth examination of TTM for postarrest care and pediatric applications.
Department of Emergency Medicine, Center for Resuscitation Science, Children's Hospital of Philadelphia; Department of Emergency Medicine, Children's Hospital of Philadelphia; Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI.
Sarah M
SM
Perman
Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
Munish
M
Goyal
Department of Emergency Medicine, Medstar Health System, Washington Hospital Healthcare System, Washington, DC.
Robert W
RW
Neumar
Department of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia.
Alexis A
AA
Topjian
Department of Emergency Medicine, Center for Resuscitation Science, Children's Hospital of Philadelphia; Department of Emergency Medicine, Children's Hospital of Philadelphia. Electronic address: gaieskid@uphs.upenn.edu.
David F
DF
Gaieski
D001930:Brain Injuries / Q000628:therapy; D019468:Disease Management; D049673:History, 20th Century; D049674:History, 21st Century; D006801:Humans; D007036:Hypothermia, Induced / Q000266:history* / Q000379:methods*; D009203:Myocardial Infarction / Q000628:therapy; D020521:Stroke / Q000628:therapy; D016896:Treatment Outcome