Skip to main content

Advertisement

SpringerLink
Log in

Minimizing Shivering During Targeted Normothermia: Comparison Between Novel Transnasal and Surface Temperature-Modulating Devices

  • Original work
  • Published:
Neurocritical Care Aims and scope Submit manuscript

An Invited Commentary to this article was published on 03 August 2023

Abstract

Background

Shivering is a common adverse effect of achieving and maintaining normothermia in neurocritical care patients. We compared the burden of shivering and shivering-related interventions between a novel transnasal temperature-modulating device (tnTMD) and surface cooling temperature-modulating devices (sTMDs) during the first 24 h of targeted normothermia in mechanically ventilated febrile neurocritical care patients.

Methods

This is a case–control study controlling for factors that impact shiver burden: age, sex, body surface area. All patients underwent transnasal cooling (CoolStat, KeyTech, Inc.) as part of an ongoing multicenter clinical trial (NCT03360656). Patients undergoing treatment with sTMDs were selected from consecutively treated patients during the same time period. Data collected included the following: core body temperature (every 2 h), bedside shivering assessment scale (BSAS) score (every 2 h), and administration of antishivering medication for a BSAS score > 1. Time to normothermia (≤ 37.5 °C), as well as temperature burden > 37.5 °C (°C × h), were compared between groups using Student’s t-test for mean differences. The proportion of patients requiring interventions, as well as the number of interventions per patient, was compared using the χ2 test. Significance was determined based on a p value < 0.05.

Results

There were 10 tnTMD patients and 30 sTMD patients included in the analysis (mean age: 62 ± 4, 30% women, body surface area = 1.97 ± 0.25). There were no differences between groups in temperature at cooling initiation (tnTMD: 38.5 ± 0.2 °C vs. sTMD: 38.7 ± 0.5 °C, p = 0.3), time to ≤ 37.5 °C (tnTMD: 1.8 ± 1.5 h vs. sTMD: 2.9 ± 1.4 h, p = 0.1), or temperature burden > 37.5 (tnTMD: − 0.4 ± 1.13 °C × h vs. sTMD median [IQR]: − 0.57 ± 0.58 °C × h, p = 0.67). The number of tnTMD patients who received pharmacologic shivering interventions was lower than the number of controls (20 vs. 67%, p = 0.01). tnTMD patients also had fewer shivering interventions per patient (0 [range: 0–3] vs. 4 [range: 0–23], p < 0.001).

Conclusions

A transnasal cooling approach achieved similar time to normothermia and temperature burden with less shivering than surface cooling. This approach may be a feasible option to consider for mechanically ventilated febrile neurocritical care patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Greer DM, Funk SE, Reaven NL, Ouzounelli M, Uman GC. Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis. Stroke. 2008;39(11):3029–35.

    Article  PubMed  Google Scholar 

  2. Khan I, Haymore J, Barnaba B, et al. Esophageal cooling device versus other temperature modulation devices for therapeutic normothermia in subarachnoid and intracranial hemorrhage. Ther Hypothermia Temp Manag. 2018;8(1):53–8.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Diringer MN. Neurocritical care fever reduction trial G. Treatment of fever in the neurologic intensive care unit with a catheter-based heat exchange system. Crit Care Med. 2004;32(2):559–64.

    Article  PubMed  Google Scholar 

  4. Mayer SA, Kowalski RG, Presciutti M, et al. Clinical trial of a novel surface cooling system for fever control in neurocritical care patients. Crit Care Med. 2004;32(12):2508–15.

    Article  PubMed  Google Scholar 

  5. Hata JS, Shelsky CR, Hindman BJ, Smith TC, Simmons JS, Todd MM. A prospective, observational clinical trial of fever reduction to reduce systemic oxygen consumption in the setting of acute brain injury. Neurocrit Care. 2008;9(1):37–44.

    Article  PubMed  Google Scholar 

  6. Badjatia N, Strongilis E, Gordon E, et al. Metabolic impact of shivering during therapeutic temperature modulation: the bedside shivering assessment scale. Stroke. 2008;39(12):3242–7.

    Article  PubMed  Google Scholar 

  7. Oddo M, Frangos S, Maloney-Wilensky E, Andrew Kofke W, Le Roux PD, Levine JM. Effect of shivering on brain tissue oxygenation during induced normothermia in patients with severe brain injury. Neurocrit Care. 2010;12(1):10–6.

    Article  CAS  PubMed  Google Scholar 

  8. Choi HA, Ko SB, Presciutti M, et al. Prevention of shivering during therapeutic temperature modulation: the Columbia anti-shivering protocol. Neurocrit Care. 2011;14(3):389–94.

    Article  PubMed  Google Scholar 

  9. Badjatia N, Gupta N, Sanchez S, et al. Safety and feasibility of a novel transnasal cooling device to induce normothermia in febrile cerebrovascular patients. Neurocrit Care. 2021;34(2):500–7.

    Article  PubMed  Google Scholar 

  10. Badjatia N, Kowalski RG, Schmidt JM, et al. Predictors and clinical implications of shivering during therapeutic normothermia. Neurocrit Care. 2007;6(3):186–91.

    Article  PubMed  Google Scholar 

  11. Lyden P, Ernstrom K, Cruz-Flores S, et al. Determinants of effective cooling during endovascular hypothermia. Neurocrit Care. 2012;16(3):413–20.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Chava R, Zviman M, Raghavan MS, et al. Rapid induction of therapeutic hypothermia using transnasal high flow dry air. Ther Hypothermia Temp Manag. 2017;7(1):50–6.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Covaciu L, Weis J, Bengtsson C, et al. Brain temperature in volunteers subjected to intranasal cooling. Intensiv Care Med. 2011;37(8):1277–84.

    Article  CAS  Google Scholar 

  14. Nordberg P, Taccone FS, Truhlar A, et al. Effect of transnasal evaporative intra-arrest cooling on functional neurologic outcome in out-of-hospital cardiac arrest: the PRINCESS randomized clinical trial. JAMA. 2019;321(17):1677–85.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Taccone FS, Hollenberg J, Forsberg S, et al. Effect of intra-arrest trans-nasal evaporative cooling in out-of-hospital cardiac arrest: a pooled individual participant data analysis. Crit Care. 2021;25(1):198.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Jarrah S, Dziodzio J, Lord C, et al. Surface cooling after cardiac arrest: effectiveness, skin safety, and adverse events in routine clinical practice. Neurocrit Care. 2011;14(3):382–8.

    Article  PubMed  Google Scholar 

  17. Madden LK, Hill M, May TL, et al. The implementation of targeted temperature management: an evidence-based guideline from the neurocritical care society. Neurocrit Care. 2017;27(3):468–87.

    Article  PubMed  Google Scholar 

Download references

Funding

This study was funded in part by the Maryland Industrial Partnerships program and CoolTech Corp.

Author information

Authors and Affiliations

  1. Program in Trauma, Shock Trauma Neurocritical Care, Department of Neurology, University of Maryland School of Medicine, 22 S. Greene Street, G7K19, Baltimore, MD, 21201, USA

    Shannon Arnold & Neeraj Badjatia

  2. Department of Pharmacy, University of Maryland Medical Center, Baltimore, USA

    Michael Armahizer

  3. Department of Cardiology, The Johns Hopkins Hospital, Baltimore, USA

    Luis F. Torres & H. Alex Choi

  4. Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington D.C., USA

    Hemant Tripathi & Harikrishna Tandri

  5. Department of Neurology, Georgetown University, Washington D.C., USA

    Hemant Tripathi & Harikrishna Tandri

  6. Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, USA

    Jason J. Chang

Authors
  1. Shannon Arnold
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael Armahizer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Luis F. Torres
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hemant Tripathi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Harikrishna Tandri
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jason J. Chang
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. H. Alex Choi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Neeraj Badjatia
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SA contributed to concept, design, acquisition of data, and drafting of the manuscript. MA contributed to the acquisition of data and critical revision of the manuscript for intellectual content. LFT contributed to acquisition of data, analysis and interpretation of data, and critical revision of the manuscript for intellectual content. HTripathi contributed to acquisition of data and analysis and interpretation of data. HTandri contributed to analysis and interpretation of data and critical revision of the manuscript for intellectual content. JJC contributed to analysis and interpretation of data and critical revision of the manuscript for intellectual content. HAC contributed to analysis and interpretation of data and critical revision of the manuscript for intellectual content. NB contributed to concept, design, analysis and interpretation of data, drafting of the manuscript, statistical analysis, obtaining funding, and administrative, technical, and material support supervision.

Corresponding author

Correspondence to Neeraj Badjatia.

Ethics declarations

Conflicts of Interest

The authors declare no conflicts of interest.

Ethical Approval/Infomed Consent

All data collection for retrospective analysis of participants undergoing sTMD was approved by the Institutional Review Board at the University of Maryland School of Medicine. Participants undergoing cooling with tnTMD were enrolled in a study that was approved at each site by the institutional review board and by the US Food and Drug Administration through an investigational device exemption and registered on ClinicalTrials.gov (NCT03360656).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Arnold, S., Armahizer, M., Torres, L.F. et al. Minimizing Shivering During Targeted Normothermia: Comparison Between Novel Transnasal and Surface Temperature-Modulating Devices. Neurocrit Care 39, 639–645 (2023). https://doi.org/10.1007/s12028-023-01793-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-023-01793-3

Keywords

Search

Navigation