Erschienen in:
Open Access
01.12.2017 | Review
Targeted temperature management in the ICU: guidelines from a French expert panel
verfasst von:
Alain Cariou, Jean-François Payen, Karim Asehnoune, Gerard Audibert, Astrid Botte, Olivier Brissaud, Guillaume Debaty, Sandrine Deltour, Nicolas Deye, Nicolas Engrand, Gilles Francony, Stéphane Legriel, Bruno Levy, Philippe Meyer, Jean-Christophe Orban, Sylvain Renolleau, Bernard Vigue, Laure De Saint Blanquat, Cyrille Mathien, Lionel Velly, for the Société de Réanimation de Langue Française (SRLF) and the Société Française d’Anesthésie et de Réanimation (SFAR) In conjunction with the Association de Neuro Anesthésie Réanimation de Langue Française (ANARLF), the Groupe Francophone de Réanimation et Urgences Pédiatriques (GFRUP), the Société Française de Médecine d’Urgence (SFMU), and the Société Française Neuro-Vasculaire (SFNV)
Erschienen in:
Annals of Intensive Care
|
Ausgabe 1/2017
Abstract
Over the recent period, the use of induced hypothermia has gained an increasing interest for critically ill patients, in particular in brain-injured patients. The term “targeted temperature management” (TTM) has now emerged as the most appropriate when referring to interventions used to reach and maintain a specific level temperature for each individual. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. This treatment is widely used in intensive care units, mostly as a primary neuroprotective method. Indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of TTM in adult and paediatric critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d’Anesthésie Réanimation [SFAR]) with the participation of the French Emergency Medicine Association (Société Française de Médecine d’Urgence [SFMU]), the French Group for Pediatric Intensive Care and Emergencies (Groupe Francophone de Réanimation et Urgences Pédiatriques [GFRUP]), the French National Association of Neuro-Anesthesiology and Critical Care (Association Nationale de Neuro-Anesthésie Réanimation Française [ANARLF]), and the French Neurovascular Society (Société Française Neurovasculaire [SFNV]). Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations: cardiac arrest, traumatic brain injury, stroke, other brain injuries, and shock. This resulted in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were experts’ opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations, which are exposed in the present article.
Introduction
The protective effects of hypothermia were first studied and described in the late 1950s and then seem to have been forgotten for roughly 20 years before intensivists revived interest in this therapeutic method [
1,
2]. Experimental data show that the neuroprotective effects of therapeutic hypothermia occur through several mechanisms of action:
Accordingly, the use of mild to moderate hypothermia has gained interest for critically ill patients, in particular brain-injured patients in order to limit the extension of initial brain lesions [
11]. This can be achieved through various methods and targeted temperatures. The term “targeted temperature management” (TTM) has emerged as the most appropriate referring to interventions used to reach and maintain a specific level temperature for each individual.
The level of targeted temperature may differ according to the situation. TTM may be used to prevent fever, to maintain normothermia, or to lower core temperature. TTM is widely used in intensive care units (ICUs) as a primary neuroprotective method, i.e. in order to protect against neuronal injury or degeneration in the central nervous system. Its indications are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the literature in order to edit national guidelines.
Methods
These guidelines were conducted by a group of experts for the French Intensive Care Society (Société de Réanimation de Langue Française [SRLF]) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d’Anesthésie Réanimation [SFAR]). The organization committee defined a list of questions to be addressed and designated experts in charge of each question. The questions were formulated using the PICO (Patient Intervention Comparison Outcome) format (
http://www.gradeworkinggroup.org/).
The method used to elaborate these recommendations was the GRADE
® method [
12]. Following a quantitative literature analysis, this method is used to separately determine the quality of available evidence, i.e. estimation of the confidence needed to analyse the effect of the quantitative intervention, and the level of recommendation. The quality of evidence is rated as follows:
-
high-quality evidence: further research is very unlikely to change the confidence in the estimate of the effect;
-
moderate-quality evidence: further research is likely to have an impact on the confidence in the estimate of the effect and may change the estimate of the effect itself;
-
low-quality evidence: further research is very likely to have an impact on the confidence in the estimate of the effect and is likely to change the estimate of the effect itself;
-
very low-quality evidence: any estimate of the effect is very unlikely.
The level of recommendation is binary (either positive or negative) and strong or weak:
The strength of the recommendations is determined according to key factors and validated by the experts after a vote, using the Delphi and GRADE Grid method [
13] that encompasses the following criteria:
-
the estimate of the effect;
-
the global level of evidence: the higher the level of evidence, the stronger the recommendation;
-
the balance between desirable and undesirable effects: the more favourable the balance, the stronger the recommendation;
-
values and preferences: in case of uncertainty or large variability, the level of evidence of the recommendation is probably weak, and values and preferences must be more clearly obtained from the affected persons (patient, physician, and decision-maker);
-
cost: the greater the costs or the use of resources, the weaker the recommendation.
The elaboration of a recommendation requires that at least 50% of voting participants have an opinion and that less than 20% of participants vote for the opposite proposition. The elaboration of a strong agreement requires the agreement of at least 70% of voting participants.
Results
Areas of recommendations
Fifteen experts and two coordinators agreed to consider questions concerning TTM and its practical implementation in five clinical situations in the intensive care setting: cardiac arrest (CA), traumatic brain injury (TBI), stroke, other brain injuries, and shock. The PubMed and Cochrane databases were searched for full articles written in English or French published after January 2005 and June 2015. In case of an absence or a very low number of publications during the considered period, the timing of publications could have been extended to 1995. The paediatric literature had a specific analysis.
The experts summarized the work and applied the GRADE® method, resulting in 30 recommendations: 3 recommendations were strong (Grade 1), 13 were weak (Grade 2), and 14 were expert opinions. After two rounds of rating and various amendments, a strong agreement from voting participants was obtained for all 30 (100%) recommendations.
TTM after traumatic brain injury
TTM after stroke, intra-cerebral haemorrhage, and subarachnoid haemorrhage
TTM in acute bacterial meningitis and status epilepticus
TTM after haemodynamic shock
Implementation and monitoring of TTM
Authors’ contributions
AC and JFP proposed the elaboration of this recommendation and manuscript in agreement with the “Société de Réanimation de Langue Française” and “Société Française d’Anesthésie et de Réanimation”; LSB, CM, and LV wrote the methodology section and gave the final version with the final presentation. ND and GD contributed to elaborate recommendations and write the rationale of question 1 (cardiac arrest). BV, GF, JFP contributed to elaborate recommendations and to write the rationale of question 2 (traumatic brain injury). SD and GA contributed to elaborate recommendations and to write the rationale of question 3 (stroke and subarachnoid haemorrhage). SL and NE contributed to elaborate recommendations and to write the rationale of question 4 (acute bacterial meningitis and status epilepticus). BL and KA contributed to elaborate recommendations and to write the rationale of question 5 (shock). JCO and ND contributed to elaborate recommendations and to write the rationale of question 6 (implementation and monitoring). AB, LSB, PM, and SR contributed to elaborate recommendations and to write the rationale paediatric recommendations. FA and YW provide references. AC, LV, and JFP drafted the manuscript. All authors read and approved the final manuscript.
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