PCAS

2.
• PCAS
• PCAS ER
•
• PCAS ICU 1
• PCAS ICU 2

PCAS
68
BLS
ROSC
HR100, BP150/80
GCS1-1-1, 36.5℃

Post Cardiac Arrest Syndrome
Post Cardiac Arrest Syndrome: A Review of Therapeutic Strategies Dion Stub et al.: Circulation. 2011;123:1428-1435

death. Whether apo
determined by cellu
mitochondrial dysfu
ders in cellular ene
release of so-called c
merous studies hav
thermia can interrup
way, thereby preve
from leading to apop
thermia seems to af
stages of the apopto
ptosis initiation (40
inhibition of caspas
(39–41, 43, 44), pre
drial dysfunction (42
of excitatory neur
modiﬁcation of intr
trations. (The latter
cussed in more deta
Apoptosis begins
postperfusion and/o
while continuing for
hrs or even longer
ptosis is one of the
be mitigated (and
vented) for some ti
viding (at least in th
Figure 1. Schematic depiction of the mechanisms underlying the protective effects of mild to
moderate hypothermia. TxA2, thromboxane A2.

2015
ROSC (
) 32 – 36℃
24 TTM

図 1 心停止アルゴリズム

PCAS EGDT
420 D.F. Gaieski et al. / Resuscitation 80 (2009) 418–424
Figure 1. The Hospital of the University of Pennsylvania’s post-cardiac arrest resuscitation treatment protocol.

PCAS
ROSC
SpO2 94%
EtCO2
BP90mmHg
12 ECG

•
• ( ; )
– (SBP 90mmHg MAP 65mmHg)

ROSC
12 ECG
• ACS
• ECG
•

• MAP80mmHg
• SBP 90mmHg 100mmHg
• MAP65 mmHg 1
Resuscitation. 2009;80:418–424.
Resuscitation. 2008;79:410–416.
Resuscitation. 2007;73:29–39

( )
• VF ROSC
(24 32 36℃)
• PEA
ROSC

H&T’s
• Hypoxia
• Hypothermia
• Hypovolemia
• Hydrogen-ion
• Hypo/Hyper-Kalemia
• Trauma
• Tension pneumothorax
• Tamponade
• Thrombosis

SBP> 100 mmHg MAP > 80 mmHg
SBP< 90 mmHg MAP< 65 mmHg
:

α β
重要ポイントをバッチリ理解！おさえておきたい循環器疾患の治療薬特集
図1 心臓，血管の自律神経支配
交感神経の興奮時副交感神経の興奮時
心拍数増加
心収縮力増加
拡張
収縮拡張
心拍数減少
心収縮力低下
β１受容体
β１受容体
β2受容体
α受容体
冠動脈
小血管
HEART 2011/12 Vol.1 No.4

μg(1000xmg)/kg/min
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1x1000 μg/20 ml
3. 60kg)
1x1000 μg/20 ml/60 kg
4. 1 60 60 ml/
1x1000 μg/20 ml/60 kg/60 0.014μg/kg/ /ml
1.0ml/ 0.014μg/kg/

Dopamine
A 100 /5ml
α/β1/β2=+/++/-
( )
( )
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1 10μg/kg/
5 10 α β
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3 20μg/kg/

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Surface cooling Arc/c Sun
398 10

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せ、体外より体温
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コントロールパネル

スタートを押すことで、設定 34℃にて低体温治療が開始する。スタートを押すことで、設定 34℃にて低体温治療が開始する。

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Resuscitation 81 (2010) 1117–1122
Contents lists available at ScienceDirect
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
Therapeutic hypothermia after cardiac arrest: A retrospective comparison of
surface and endovascular cooling techniquesଝ
Michael A. Gilliesa,∗
, Rosalie Pratta
, Craig Whiteleya
, Jamie Borga
, Richard J. Bealea
, Shane M. Tibbyb
a
Department of Intensive Care, Guy’s and St. Thomas’ NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom
b
Department of Pediatric Intensive Care, Evelina Children’s Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, United Kingdom
a r t i c l e i n f o
Article history:
Received 27 January 2010
Received in revised form 23 April 2010
Accepted 4 May 2010
Keywords:
Critical care
Hypothermia
Cardiac arrest
a b s t r a c t
Objectives: Therapeutic hypothermia (32–34 ◦
C) is recommended for comatose survivors of cardiac arrest;
however, the optimal technique for cooling is unknown. We aimed to compare therapeutic hypothermia
using either surface or endovascular techniques in terms of efficacy, complications and outcome.
Design: Retrospective cohort study.
Setting: Thirty-bed teaching hospital intensive care unit (ICU).
Patients: All patients (n = 83) undergoing therapeutic hypothermia following cardiac arrest over a 2.5-year
period. The mean age was 61 ± 16 years; 88% of arrests occurred out of hospital, and 64% were ventricular
fibrillation/tachycardia.
Interventions: Therapeutic hypothermia was initiated in the ICU using iced Hartmann’s solution, followed
by either surface (n = 41) or endovascular (n = 42) cooling; choice of technique was based upon endovas-
cular device availability. The target temperature was 32–34 ◦
C for 12–24 h, followed by rewarming at a
rate of 0.25 ◦
C h− 1
.
Measurements and main results: Endovascular cooling provided a longer time within the target tempera-
ture range (p = 0.02), less temperature fluctuation (p = 0.003), better control during rewarming (0.04), and
a lower 48-h temperature load (p = 0.008). Endovascular cooling also produced less cooling-associated
complications in terms of both overcooling (p = 0.05) and failure to reach the target temperature (p = 0.04).
After adjustment for known confounders, there were no differences in outcome between the groups in
terms of ICU or hospital mortality, ventilator free days and neurological outcome.
Conclusion: Endovascular cooling provides better temperature management than surface cooling, as well
as a more favorable complication profile. The equivalence in outcome suggested by this small study
requires confirmation in a randomized trial.
© 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Cardiovascular disease remains a leading cause of death in the
developed world and survival from cardiac arrest with good neu-
rological outcome is uncommon. In the United Kingdom less than
30% of patients admitted to the intensive care unit (ICU) following
cardiac arrest survive to hospital discharge1 and the majority of
2
tuted where possible for comatose survivors of cardiac arrest.6
Several controversies exist concerning TH, especially with regard
to the most efficient cooling technique, duration of hypothermia,
and patient selection.6
Therapeutic hypothermia can be induced rapidly by infusion
of cold (4 ◦C) crystalloid solution7 following which hypothermia
is maintained using either surface or endovascular techniques.
scitation 81 (2010) 1117–1122
o
-
n
-
-
y
t
Fig. 1. Distribution of cooling methods used. E refers to the period January through
June, and L to July through December.
Gillies MA, et al Resuscitation (2010) 81;1117-1122

1120 M.A. Gillies et al. / Resuscitation 81 (2010) 1117–1122
Fig. 2. Seventy-two hour profiles of temperature for the two groups. Data are mean,
error bars 95% confidence interval for the mean.
The area under the temperature–time curve over 48 h was signifi-
cantly less in the endovascular group (Table 1 and Fig. 2, p = 0.008).
To exclude a learning effect (as the majority of patients in the first
groups. The apparent increase in bleeding in
(14% versus 2%) did not reach statistical sign
the patients in the endovascular group who s
was as a result of a traumatic pre-hospital intu
ooze or minor bleeding reported around the e
site.
4.4. Outcome measures
There was no difference in unadjusted IC
ity, ICU-free days or ventilator-free days betw
The unadjusted proportion with poor neuro
also similar. Multivariable analysis (Table
factors were consistently associated with m
APACHE II score and (b) cardiac arrests o
lar fibrillation/pulseless ventricular tachycar
for potential confounders (Table 3), there w
ICU mortality, hospital mortality or neurol
endovascular compared to surface cooling.
5. Discussion
The role of TH in comatose survivors
increasingly recognized,3–5 and there is incr
a standardised approach including coronary r
Gillies MA, et al Resuscitation (2010) 81;1117-1122
p=0.003
p=0.04
p=0.008
p=0.05
p=0.04

Background—Targeted temperature management is recommended after out-of-hospital cardiac arrest. Whether advanced
internal cooling is superior to basic external cooling remains unknown. The aim of this multicenter, controlled trial was
to evaluate the benefit of endovascular versus basic surface cooling.
Methods and Results—Inclusion criteria were the following: age of 18 to 79 years, out-of-hospital cardiac arrest related to
a presumed cardiac cause, time to return of spontaneous circulation <60 minutes, delay between return of spontaneous
circulation and inclusion <240 minutes, and unconscious patient after return of spontaneous circulation and before the start
of cooling. Exclusion criteria were terminal disease, pregnancy, known coagulopathy, uncontrolled bleeding, temperature
on admission <30°C, in-hospital cardiac arrest, immediate need for extracorporeal life support or hemodialysis. Patients
were randomized between 2 cooling strategies: endovascular femoral devices (Icy catheter, Coolgard, Zoll, formerly
Alsius; n=203) or basic external cooling using fans, a homemade tent, and ice packs (n=197). The primary end point, that
is, favorable outcome evaluated by survival without major neurological damage (Cerebral Performance Categories 1–2)
at day 28, was not significantly different between groups (odds ratio, 1.41; 95% confidence interval, 0.93–2.16; P=0.107).
Improvement in favorable outcome at day 90 in favor of the endovascular group did not reach significance (odds ratio,
1.51; 95% confidence interval, 0.96–2.35; P=0.07). Time to target temperature (33°C) was significantly shorter and target
hypothermia was more strictly maintained in the endovascular than in the surface group (P<0.001). Minor side effects
directly related to the cooling method were observed more frequently in the endovascular group (P=0.009).
Conclusion—Despite better hypothermia induction and maintenance, endovascular cooling was not significantly superior to
basic external cooling in terms of favorable outcome.
Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00392639.
(Circulation. 2015;132:182-193. DOI: 10.1161/CIRCULATIONAHA.114.012805.)
Key Words: endovascular procedures ◼ heart arrest ◼ hypothermia ◼ prognosis ◼ therapy
Endovascular Versus External Targeted Temperature
Management for Patients With Out-of-Hospital
Cardiac Arrest
A Randomized, Controlled Study
Nicolas Deye, MD; Alain Cariou, MD, PhD; Patrick Girardie, MD; Nicolas Pichon, MD;
Bruno Megarbane, MD, PhD; Philippe Midez, MD; Jean-Marie Tonnelier, MD;
Thierry Boulain, MD; Hervé Outin, MD; Arnaud Delahaye, MD; Aurélie Cravoisy, MD;
Alain Mercat, MD, PhD; Pascal Blanc, MD; Charles Santré, MD; Hervé Quintard, MD;
François Brivet, MD; Julien Charpentier, MD; Delphine Garrigue, MD;
Bruno Francois, MD; Jean-Pierre Quenot, MD; François Vincent, MD;
Pierre-Yves Gueugniaud, MD, PhD; Jean-Paul Mira, MD, PhD; Pierre Carli, MD, PhD;
Eric Vicaut, MD, PhD; Frédéric J. Baud, MD; for the Clinical and Economical Impact of Endovascular
Cooling in the Management of Cardiac Arrest (ICEREA) Study Group*
Resuscitation Science
In most studies, the intravascular method seems to enable
more rapid induction of cooling and more accurate maintenance
of TTM compared with external cooling method.8,11–14,24,33–35
In
our study, we failed to demonstrate a clear clinical superiority of
the endovascular cooling versus basic external cooling for the
management of OHCA patients, despite important differences
in the induction and maintenance phases of TTM.According to
the literature, the level of evidence to assess the superiority of
intravascular cooling on the prognosis after CA remains poor.
One small, nonrandomized, retrospective study found a better
neurological outcome favoring the endovascular method versus
basic external cooling.13
Conversely, 3 other studies comparing
endovascular with surface cooling methods found no signifi-
cant difference in survival with good neurological outcome
after a CA.10,11
However, the time from CA to achieving TH
was similar for both devices in 2 of these studies,10,14
whereas
the number of patients enrolled was rather limited,11,14
lead-
ing to debatable conclusions about its potential clinical impact.
Finally, most human studies found results similar to ours when
several other devices were used to early achieve TH, especially
with cold intravenous fluids.17–22
Despite a reduced delay to
reach the TT with better maintenance of TH, and a decreased
32
33
34
35
36
0 10 20 30 40 50 60 70 80
Time (hours)
Temperature(°
Figure 2. Temperature distribution during the targeted temperature management (TTM) phase (eg, within the first 3 days after cardiac
arrest). Data are expressed as mean±SD. The times to reach the 34°C and 33°C target temperatures were significantly shorter in the
endovascular group (blue line) than in the external group (red line). The stability of temperature values was significantly better in the
endovascular group during the maintenance phase of the TTM.
Figure 3. Cumulative incidence of favorable outcome (eg, occurrence of Cerebral Performance Categories [CPC] 1 and 2) within 90 days
188 Circulation July 21, 2015
13
32
33
34
35
36
37
38
39
40
0 10 20 30 40 50 60 70 80
Time (hours)
Temperature(°C)
Figure 2. Temperature distribution during the targeted temperature management (TTM) phase (eg, within the first 3 days after cardiac
arrest). Data are expressed as mean±SD. The times to reach the 34°C and 33°C target temperatures were significantly shorter in the
endovascular group (blue line) than in the external group (red line). The stability of temperature values was significantly better in the
endovascular group during the maintenance phase of the TTM.
Circulation. 2015;132:182-193.

update
ROSC 32 36℃
24
TTM 72
TTM ,
ROSC 72

Twenty-Four Hours of Mild Hypothermia in
Unsedated Newborn Pigs Starting after a Severe
Global Hypoxic-Ischemic Insult Is Not
Neuroprotective
MARIANNE THORESEN, SAULIUS SATAS, ELSE MARIT LØBERG, ANDREW WHITELAW,
DOMINIQUE ACOLET, CARL LINDGREN, JULIET PENRICE, NICOLA ROBERTSON,
EGIL HAUG, AND PETTER ANDREAS STEEN
Departments of Experimental Medicine [M.T., S.S., A.W., P.A.S.], Pathology [E.M.L.], Paediatrics [C.L.],
and Anaesthesiology [P.A.S.], Ullevål Hospital, Oslo, Norway; Department of Endocrinology, Aker
University Hospital, Oslo, Norway [E.H.]; Division of Child Health, University of Bristol, United
Kingdom [M.T., S.S., A.W.]; Department of Pediatrics, Chelsea and Westminster Hospital, London, United
Kingdom [D.A., J.P.]; Department of Pediatrics, University College Hospital, London, United Kingdom
[J.P.]; and Department of Pediatrics, Imperial College, London, United Kingdom [N.R.]
Three to 12 h of mild hypothermia (HT) starting after hypoxia-
ischemia is neuroprotective in piglets that are anesthetized during
HT. Newborn infants suffering from neonatal encephalopathy often
ventilate spontaneously and are not necessarily sedated. We aimed
to test whether mild posthypoxic HT lasting 24 h was neuroprotec-
tive if the animals were not sedated. Thirty-nine piglets (median
The HT animals shivered and were more active. The sham control
group (n ϭ 3) shivered but had normal physiology and neuropa-
thology. Plasma cortisol was signiﬁcantly higher in the HT group
during the HT period, 766 Ϯ 277 versus 244 Ϯ 144 ␮M at 24 h.
Mild postinsult HT for 24 h was not neuroprotective in unsedated
piglets and did not reduce the number of animals that developed
0031-3998/01/5003-0405
PEDIATRIC RESEARCH Vol. 50, No. 3, 2001
Copyright © 2001 International Pediatric Research Foundation, Inc. Printed in U.S.A.
ABSTRACT
Thoresen M; Pediatr Res 50: 405–411, 2001

values. The decline in cortisol seen in the NT animals is normal
for pigs from d 1 to 3 (20).
DISCUSSION
We found no neuroprotective effect of 24-h posthypoxic HT
based on neuropathology or a reduction in the number of
animals that developed seizures. This finding is in contrast with
previous studies (21) that demonstrate neuroprotection in the
newborn pig (1, 6), lamb (4), and rat (2, 3, 7) by use of
posthypoxic HT lasting from 3 to 76 h. No study in newborn
animals has compared the effect of different durations of HT.
Moderate neuroprotection was found at 3-d survival after 3 h of
4° reduction (6). Twelve hours of 4° HT showed better pro-
tection in another piglet study (1). In both studies, the animals
were fully anesthetized during HT. Based on these findings, we
choose 24 h as a duration likely to be effective. The choice of
a 4° temperature reduction was based on data from adult rats
(22) and our pilot temperature study (16) as well as knowledge
of possible adverse effects with moderate hypothermia (23).
Although one might suggest that the failure of neuroprotec-
tion could be connected to the absence of vessel occlusion in
our model, we find that an unlikely explanation because our
model does achieve a significant degree of ischemia secondary
to hypoxic cardiodepression. We have found partial neuropro-
tection in our model with only 3 h of HT under anesthesia.
Also, in a cerebral microdialysis study, we found a reduction in
excitatory amino acids and citrulline/arginine ratio in the HT
compared with the NT animals (18). HI brain injury in human
newborns is not due to large vessel occlusion, and our model
produces widespread brain injury with an anatomical distribu-
tion similar to that found in the full-term infant.
We speculate that the lack of protection in this study may be
due to the stress of being cooled while awake, as previous
studies on piglets that achieved protection were all performed
on anesthetized animals.
The current study is, to our knowledge, the only experimen-
tal study in which the newborn pigs have not been anesthetized
during posthypoxic HT.
Figure 3. Upper panel shows the mean (ϮSD) Trectal in the NT and HT
groups throughout the whole experimental period. Only during induced HT is
there a difference in temperature. Middle panel shows the MABP in the NT and
HT groups. There is never a difference in blood pressure between the groups.
Figure 4. Plasma cortisol levels in the HT (n ϭ 18) and NT (n ϭ 18) groups
of animals. Rw takes place from 24 to 30 h after the insult.
Thoresen M; Pediatr Res 50: 405–411, 2001
↓
HT group for 24 h according to protocol. MABP or HR was
similar in the HT and NT groups (Fig. 3).
Cortisol. In the HT group, plasma cortisol rose during the
24-h HT period to values 3 times the NT values (Fig. 4) and
was significantly higher. After rewarming for 6 h, the HT
values had normalized and were not different from the NT
values. The decline in cortisol seen in the NT animals is normal
for pigs from d 1 to 3 (20).
DISCUSSION
We found no neuroprotective effect of 24-h posthypoxic HT
based on neuropathology or a reduction in the number of
animals that developed seizures. This finding is in contrast with
previous studies (21) that demonstrate neuroprotection in the
newborn pig (1, 6), lamb (4), and rat (2, 3, 7) by use of
posthypoxic HT lasting from 3 to 76 h. No study in newborn
animals has compared the effect of different durations of HT.
Moderate neuroprotection was found at 3-d survival after 3 h of
4° reduction (6). Twelve hours of 4° HT showed better pro-
tection in another piglet study (1). In both studies, the animals
were fully anesthetized during HT. Based on these findings, we
choose 24 h as a duration likely to be effective. The choice of
a 4° temperature reduction was based on data from adult rats
(22) and our pilot temperature study (16) as well as knowledge
of possible adverse effects with moderate hypothermia (23).
Although one might suggest that the failure of neuroprotec-
tion could be connected to the absence of vessel occlusion in
Figure 4. Plasma cortisol levels in the HT (n ϭ 18) and NT (n ϭ 18) groups
of animals. Rw takes place from 24 to 30 h after the insult.
409HYPOTHERMIC NEUROPROTECTION AND STRESS IN PIGLETS

TTM
: Analgesia
: Seda-on
: Neuromuscular Block Agents: NMBA
PAD !?

Chamorro C; Anesth Analg 2010;110:1328-35
American Society of Critical Care Anesthesiologists
Section Editor: Michael J. Murray
Anesthesia and Analgesia Protocol During
Therapeutic Hypothermia After Cardiac Arrest: A
Systematic Review
Carlos Chamorro, MD, PhD,* Jose M. Borrallo, MD,† Miguel A. Romera, MD,* Jose A. Silva, MD,†
and Ba´rbara Balandín, MD*
BACKGROUND: Present practice guidelines recommend sedative-analgesic and neuromuscular
blocking administration during therapeutic hypothermia in comatose patients after cardiac
arrest. However, none suggests the best administration protocol. In this study, we evaluated
intensivists’ preferences regarding administration.
METHODS: A systematic literature review was conducted to identify clinical studies published
between 1997 and July 2009. Selected articles had to meet the following criteria: use of
hypothermia to improve neurologic outcome after cardiac arrest, and specific mention of the
sedative protocol used. We checked drugs and dose used, the reason for their administration,
and the specific type of neurologic and neuromuscular monitoring used.
RESULTS: We identified 44 studies reporting protocols used in 68 intensive care units (ICUs)
from various countries. Midazolam, the sedative used most often, was used in 39 ICUs at
doses between 5 mg/h and 0.3 mg/kg/h. Propofol was used in 13 ICUs at doses up to 6
mg/kg/h. Eighteen ICUs (26%) did not report using any analgesic. Fentanyl was the analgesic
used the most, in 33 ICUs, at doses between 0.5 and 10 ␮g/kg/h, followed by morphine in
4 ICUs. Neuromuscular blocking drugs were routinely used to prevent shivering in 54 ICUs
and to treat shivering in 8; in 1 ICU, their use was discouraged. Pancuronium was used the
most, in 24 ICUs, followed by cisatracurium in 14. Four ICUs used neuromuscular blocking
drug administration guided by train-of-four monitoring and 3 ICUs used continuous monitoring
of cerebral activity.
CONCLUSIONS: There is great variability in the protocols used for anesthesia and analgesia
during therapeutic hypothermia. Very often, the drug and the dose used do not seem the most
appropriate. Only 3 ICUs routinely used electroencephalographic monitoring during paralysis. It
is necessary to reach a consensus on how to treat this critical care population. (Anesth Analg
2010;110:1328–35)
The clinical use of mild hypothermia, defined as a
reduction of body temperature to 32°C to 34°C, is the
only treatment that has been proven effective in
randomized clinical trials for improving neurologic out-
come after cardiac arrest. In 2002, results of 2 clinical trials
meta-analysis.3–12
According to international guidelines,
the use of therapeutic hypothermia is recommended for
the treatment of comatose cardiac arrest patients. In 2003,
the International Liaison Committee on Resuscitation
advised that unconscious post–out-of-hospital cardiac
arrest patients should be cooled when the initial rhythm

Table 1. Selected Sedatives and Analgesics, Type and Dose, in the Different Published Studies
Authors Setting
Year of the
study N Sedative Dose Analgesic Dose
Bernard et al.21
Melbourne 1993–1996 22 Not specified As required No
Zeiner et al.22
Vienna 1995–1996 27 Midazolam 0.16–0.23 mg/kg/h Fentanyl 3–4 ␮g/kg/h
Nagao et al.23
Tokyo 1996–1998 50 Midazolam Not specified No
Bernard et al.1
4 Australian ICUs 1996–1999 43 Midazolam Small doses, as
required
No
HACA2
9 ICUs (Austria 2,
Belgium 2, Germany 2,
Italy 2, Finland 1)
1996–2001 137 Midazolam 0.125 mg/kg/h Fentanyl 2 ␮g/kg/h
Felberg et al.24
Houston 1998–1999 9 Propofol Not specified No
Hachimi-Idrissi et al.25
Brussels 1999 16 Midazolam Not specified Fentanyl Not specified
Sakurai et al.26
Tokyo 1999–2003 26 Midazolam 0.1–0.3 mg/kg/h Buprenorphine 0.05–0.1 mg/h
Laurent et al.27
2 French ICUs 2000–2002 22 Midazolam 0.1 mg/kg/h Morphine 0.1 mg/kg/h
Al-Senani et al.28
3 USA ICUs 2001–2002 13 Not specified No
Busch et al.29
Stavanger 2002–2003 27 Midazolam Not specified Fentanyl Not specified
Oddo et al.30
Lausanne 2002–2004 137 Midazolam 0.1 mg/kg/h Fentanyl 1.5 ␮g/kg/h
Rosetti et al.31
2004–2008
Falkenbach et al.32
5 Finnish ICUs 2002–2006 154 Propofol Not specified Fentanyl Not specified
Laish-Farkash et al.33
Israel 2002–2006 51 Midazolam Not specified No
Belliard et al.34
Paris 2003–2005 32 Midazolam Not specified Sufentanil Not specified
Sunde et al.35
Oslo 2003–2005 40 Propofol Not specified Fentanyl Not specified
Hay et al.36
Edinburgh 2003–2005 61 Not specified No
Knafelj et al.37
Ljubljana 2003–2005 32 Midazolam Not specified No
Hovdenes et al.38
Oslo 2003–2005 50 Midazolam Not specified Fentanyl Not specified
Merchant et al.39
Chicago, Richmond (USA),
Bristol (UK)
2003–2005 32 Not specified Not specified
Scott et al.40
Oklahoma 2003–2005 49 Lorazepam Not specified Not specified At discretion
Al Thenayan et al.41
London (Canada) 2003–2007 37 Midazolam Not specified Fentanyl Not specified
Kagawa et al.42
Hiroshima 2003–2008 80 Propofol 2–6 mg/kg/h Morphine 0.017 mg/kg/h
Bekkers et al.43
Maastricht 2004–2005 43 Midazolam Not specified Piritramide Not specified
Haugk et al.44
Vienna 2004–2005 28 Midazolam 0.21 mg/kg/h Fentanyl 36 ␮g/h
Rundgren et al.45
Lund 2004–2005 34 Propofol 2–4 mg/kg/h Fentanyl 1–2 ␮g/kg/h
Bruel et al.46
Caen 2004–2006 33 Ketamine 1 mg/kg/h Fentanyl 1.5 ␮g/kg/h
Tiainen et al.47
Helsinki 2004–2006 36 Midazolam 0.125 mg/kg/h Fentanyl 2 ␮g/kg/h
Bro-Jeppesen et al.48
Copenhagen 2004–2006 79 Propofol 0.3–4 mg/kg/h Fentanyl 100 ␮g/h
Wolff et al.49
Schwerin 2004–2006 49 Propofol 200 mg/h Fentanyl 50 ␮g/h
Hammer et al.50
2 French ICUs 2004–2006 22 Midazolam 0.125 mg/kg/h Fentanyl 2 ␮g/kg/h
Gal et al.51
Brno 2004–2006 43 Midazolam 0.125 mg/kg/h Sufentanil 0.5 ␮g/kg/h
Kliegel et al.52
Vienna 2005–2006 20 Midazolam 0.2–0.25 mg/kg/h Fentanyl 10 ␮g/kg/h
Rittenberger et al.53
Pittsburgh 2005–2007 69 Benzodiaze-pine
or propofol
Not specified No
Stammet et al.54
Luxembourg 2005–2007 45 Midazolam 0.2 mg/kg/h Fentanyl 1.5 ␮g/kg/h
Derwall et al.55
5 hospitals, Aachen
(Germany)
2005–2007 37 Midazolam or
propofol
Not specified Opioid Not specified
Legriel et al.56
Versailles 2005–2008 51 Propofol 2–5 mg/kg/h No
Takeuchi et al.57
Kitasato 2005–2008 25 Midazolam Not specified No
Aghenta et al.58
New York 2006 8 Midazolam Not specified No
Jimmink et al.59
Amsterdam 2006–2007 27 Midazolam 5 mg/h Morphine 2 mg/h
Storm et al.60
Berlin 2006–2007 52 Midazolam 0.125 mg/kg/h Fentanyl 2 ␮g/kg/h
Pichon et al.61
Limoges Published in
2007
40 Midazolam Not specified No
Nordmark et al.62
Uppsala Published in
2009
4 Propofol 0.3–4 mg/kg/h Fentanyl 0.5–2 ␮g/kg/h

Table 2. Selected Neuromuscular Blockers, Type and Dose, in the Different Published Studies
N ‫؍‬ Number of
treated patients
Author Setting
Year of the
study
Patients
included
Neuromuscular
blocker Dose Indication
Status epilepticus
incidence and
monitoring
Bernard et al.21
Melbourne 1993–1996 22 Vecuronium Not specified To promote cooling,
(withheld when
cooled)
36%
Zeiner et al.22
Vienna 1995–1996 27 Pancuronium 0.01–0.02 mg/
kg/h
To prevent shivering 0
Nagao et al.23
Tokyo 1996–1998 50 Pancuronium Not specified Not specified No data
Bernard et al.1
4 Australian ICUs 1996–1999 43 Vecuronium Small doses, as
required
To prevent shivering No data
HACA2
9 ICUs (Austria 2,
Belgium 2,
Germany 2, Italy
2, Finland 1)
1996–2001 137 Pancuronium 0.1 mg/kg Every 2 hours to
prevent shivering
7%
Felberg et al.24
Houston 1998–1999 9 Vecuronium Infusion. Not
specified
To control shivering 44% during rewarming
Hachimi-Idrissi et al.25
Brussels 1999 16 Pancuronium 0.05 mg/kg/h To prevent shivering No data
Sakurai et al.26
Tokyo 1999–2003 26 Pancuronium 0.05–0.1 mg/
kg/h
Laurent et al.27
2 French ICUs 2000–2002 22 Pancuronium 1–4 mg/h To prevent shivering No data
Al-Senani et al.28
3 USA ICUs 2001–2002 13 Not specified To prevent shivering 23%
Busch et al.29
Stavanger 2002–2003 27 Cisatracurium Not specified To prevent shivering 0
Oddo et al.30
Lausanne 2002–2004 137 Vecuronium Bolus 0.1 mg/kg
TOF
monitoring
To prevent shivering 34.8%
Rosetti et al.31
2004–2008
Falkenbach et al.32
Israel 2002–2006 51 Atracurium Not specified To prevent shivering 20%
Laish-Farkash et al.33
5 Finnish ICUs 2002–2007 154 Cisatracurium Not specified To prevent shivering No data
Belliard et al.34
Paris 2003–2005 32 Cisatracurium Not specified To prevent shivering No data
Sunde et al.35
Oslo 2003–2005 40 Pancuronium or
cisatracurium
Not specified When indicated 18%
Hay et al.36
Edinburgh 2003–2005 61 Atracurium Not specified To control shivering No data
Knafelj et al.37
Ljubljana 2003–2005 32 Vecuronium 0.08–0.1 mg/kg Bolus to control
shivering
No data
Hovdenes et al.38
Oslo 2003–2005 50 Cisatracurium Not specified To prevent shivering No data
Merchant et al.39
Chicago, Richmond
(USA), Bristol
(UK)
2003–2005 32 Not specified Not specificied No data
Scott et al.40
Oklahoma 2003–2005 49 Pancuronium Not specified To prevent shivering No data
Al Thenayan et al.41
London (Canada) 2003–2007 37 Cisatracurium TOF monitoring To prevent shivering 21%
Kagawa et al.42
Hiroshima 2003–2008 80 Pancuronium 0.1 mg/kg every
2 h
Bekkers et al.43
Maastricht 2004–2005 43 Pancuronium Not specified To prevent shivering No data
Haugk et al.44
Vienna 2004–2005 28 Rocuronium 0.5 mg/kg/h To prevent shivering No data
Rundgren et al.45
Lund 2004–2005 34 Rocuronium Not specified To prevent shivering 20%. use of EEG
Bruel et al.46
Caen 2004–2006 33 Atracurium 0.5 mg/kg/h To prevent shivering No data
Tiainen et al.47
Helsinki 2004–2006 36 Pancuronium 0.05 mg/kg/h
TOF
monitoring
Bro-Jeppesen et al.48
Copenhagen 2004–2006 79 Cisatracurium 0.06–0.12 mg/
kg/h
To control shivering No data
Wolff et al.49
Schwerin 2004–2006 49 Atracurium Not specified To prevent shivering No data
Hammer et al.50
2 French ICUs 2004–2006 22 Pancuronium 0.05 mg/kg/h To prevent shivering No data
Gal et al.51
Brno 2004–2006 43 Pancuronium 0.1 mg/kg To prevent shivering No data
Kliegel et al.52
Vienna 2005–2006 20 Rocuronium 0.5 mg/kg/h To prevent shivering No data
Rittenberger et al.53
Pittsburgh 2005–2007 69 Discouraged
use
No data
Stammet et al.54
Luxembourg 2005–2007 45 Cisatracurium 0.1 mg/kg/h To prevent shivering 8.9% use of BIS®
Derwall et al.55
5 hospitals,
Aachen
(Germany)
2005–2007 37 Rocuronium or
pancuronium
Not specified To prevent shivering No data
Legriel et al.56
Versailles 2005–2008 51 Cisatracurium 0.18 mg/kg/h
TOF
monitoring
To prevent shivering 10% use of EEG
Takeuchi et al.57
Kitasato 2005–2008 25 Vecuronium Not specified To prevent shivering No data
Aghenta et al.58
New York 2006 8 Cisatracurium Not specified To control shivering 25%
Jimmink et al.59
Amsterdam 2006–2007 27 Rocuronium Not specified To control shivering No data
Storm et al.60
Berlin 2006–2007 52 Pancuronium Repetitive doses To prevent shivering No data
Pichon et al.61
Limoges Published in
2007
40 Pancuronium Bolus To control shivering 0%
Nordmark et al.62
Uppsala Published in
2009
4 Rocuronium Bolus or 0.15
mg/kg/h
EEG ϭ electroencephalographic monitoring; BIS ϭ bispectral index; TOF ϭ train-of-four.

(skin warming)
Mg 4g
1) , 2) MDZ
1) 2)
Bair Hugger

Midazolam
γ (GABA) Cl
.
0.03mg/kg/hr
.
48 72 (1-
hydroxylmethylmidazolam)
.

Propofol
GABA
300
700
(propofol infusion
syndrome)

Dexmedetomidine
α2
α2
0.2 0.7μg/kg/hr

Anesthesiology:
October 1997 - Volume 87 - Issue 4 - p 835–841
Clinical Investigations
Dexmedetomidine Does Not Alter the Sweating
Threshold, But Comparably and Linearly Decreases the
Vasoconstriction and Shivering Thresholds
Talke, Pekka MD; Tayefeh, Farzin MD; Sessler, Daniel I. MD; Jeffrey,
Renee BA; Noursalehi, Mojtaba PhD; Richardson, Charles PhD
Author Information
Abstract
Background:: Clonidine decreases the vasoconstriction and shivering thresholds.
It thus seems likely that the alpha2 agonist dexmedetomidine will also impair
control of body temperature. Accordingly, the authors evaluated the dose-
dependent effects of dexmedetomidine on the sweating, vasoconstriction, and
shivering thresholds. They also measured the effects of dexmedetomidine on
heart rate, blood pressures, and plasma catecholamine concentrations.
Methods:: Nine male volunteers participated in this randomized, double-blind,
cross-over protocol. The study drug was administered by computer-controlled
infusion, targeting plasma dexmedetomidine concentrations of 0.0, 0.3, and 0.6
ng/ml. Each day, skin and core temperatures were increased to provoke sweating
and then subsequently reduced to elicit vasoconstriction and shivering. Core-
temperature thresholds were computed using established linear cutaneous
contributions to control of sweating, vasoconstriction, and shivering. The dose-
dependent effects of dexmedetomidine on thermoregulatory response thresholds
were then determined using linear regression. Heart rate, arterial blood
pressures, and plasma catecholamine concentrations were determined at
baseline and at each threshold.
→

Table 4. Drugs that can be used to control shivering
Drug Efficacy
Hypotensive
Effect
Sedative
Effecta
Additional Comments, Advantages, and Disadvantages
Magnesium (2–3 g)b
ϩϩ ϩ Ϫ Advantages: some evidence for direct neuroprotective
effects of Mg. “Pre-emptive” correction of
hypothermia-induced Mg depletion
Propofol (20–150 mg)b
ϩϩϩ ϩϩϩ ϩϩϩϩ Advantages: brief-acting. Anti-seizure effect.
Disadvantage: more pronounced hypotension
Benzodiazepines (dose
depending on type
of drug; e.g.
midazolam 2.5–10
mg)b
ϩϩ ϩ ϩϩϩϩ Advantages: less hypotension. Disadvantages:
Complicates neurological evaluation. Reduced
metabolism during cooling can lead to drug
accumulation with persistent sedative effect after
rewarming
Meperidine 10–25 mg ϩϩϩϩ ϩ ϩϩ Advantages: rapid (1–5 mins) effect. Effect lasts
longer than with quick-acting opioids. Effect more
pronounced than other opioids because of activity
at kappa receptors. Relatively mild hypotensive
effect. Disadvantages: complicates neurological
evaluation. Slower metabolism during cooling.
Quick-acting opiates:
fentanyl 50–100
␮g,b
alfentanyl
100–250 ␮g
ϩϩϩ ϩ ϩϩ Advantages: rapid (1–5 mins) effect. Relatively mild
hypotensive effect. Disadvantages: complicates
neurological evaluation. Decreased drug
metabolism during cooling
Morphine 2.5–5 mgb
ϩϩϩ ϩϩϩ ϩϩ Advantage: low costs; additional sedative effect.
Disadvantages: delayed (20 mins) effect. Greater
hypotensive effect compared with fentanyl
Dexmedetomidine
50–100 ␮gb
ϩϩ ϩ ϩϩ Advantages: brief-acting; only mild hypotension.
Disadvantages: only moderately effective;
expensive. Currently not available in Europe
Clonidine 75–200 ␮gb
ϩϩϩ ϩϩϩϩ ϩ Effect in 4–7 mins. Disadvantages: Hypotension,
additional bradycardia
Ketanserin 10 mgb
ϩϩ ϩϩ Ϫ Effect in 4–7 mins. Advantages: increases cooling
rate. Disadvantage: moderate hypotensive effect
Tramadol 50–100 mg ϩϩ ϩϩ ϩϩ More rapid effect than morphine (Ϯ5 mins).
Relatively mild hypotensive effect. Disadvantages:
complicates neurological evaluation. Metabolism
decreases during hypothermia. Can cause seizures
Urapidil 10–20 mg ϩϩϩ? ϩϩϩ Ϫ Conflicting results of studies on efficacy.
Disadvantage: pronounced hypotensive effect
Drug Efficacy
Hypotensive
Effect
Sedative
Effecta
depending on type
of drug; e.g.
midazolam 2.5–10
mg)b
rewarming
fentanyl 50–100
␮g,b
alfentanyl
100–250 ␮g
Dexmedetomidine
50–100 ␮gb
Ketanserin 10 mgb
Drug Efficacy
Hypotensive
Effect
Sedative
Effecta
depending on type
of drug; e.g.
midazolam 2.5–10
mg)b
rewarming
fentanyl 50–100
␮g,b
alfentanyl
100–250 ␮g
Dexmedetomidine
50–100 ␮gb
Ketanserin 10 mgb
Drug Efficacy
Hypotensive
Effect
Sedative
Effecta
depending on type
of drug; e.g.
midazolam 2.5–10
mg)b
rewarming
fentanyl 50–100
␮g,b
alfentanyl
100–250 ␮g
Dexmedetomidine
50–100 ␮gb
Magnesium (2–3 g) ϩϩ ϩ Ϫ Advantages: some evidence for direct neuroprotective
depending on type
of drug; e.g.
midazolam 2.5–10
mg)b
rewarming
fentanyl 50–100
␮g,b
alfentanyl
100–250 ␮g
Dexmedetomidine
50–100 ␮gb
Ketanserin 10 mgb
Doxapram 100 mg ϩϩϩ Ϫ Ϫ Advantages: rapid action (1–5 mins). Can increase
heart rate and blood pressure. Disadvantages: can
cause laryngeal spasms
Physostigmine 2 mg ϩϩ ϩϩ Ϫ Can cause additional bradycardia and hypotension
Flumazenil 0.25–0.5
mg
ϩϩ Ϫ Ϫ Few data available. Efficacy may be lower outside the
perioperative setting
Nefopam 10–20 mg ϩϩϩ Ϫ ϩ Can induce convulsions and anaphylactic reactions.
Polderman KH, Herold I: Therapeutic hypothermia and cotrolled normothermia in the intensive care unit:
Practical considerations, side effects, and cooling methods. Crit Care Med 37: 1101-20, 2009

Thor W. Bjelland
Ola Dale
Kjell Kaisen
Bjørn O. Haugen
Stian Lydersen
Kristian Strand
Pa˚l Klepstad
Propofol and remifentanil versus midazolam
and fentanyl for sedation during therapeutic
hypothermia after cardiac arrest:
a randomised trial
Received: 19 September 2011
Accepted: 12 January 2012
Published online: 12 April 2012
Ó Copyright jointly held by Springer and
ESICM 2012
Trial registration: ClinicalTrials.gov
NCT00667043
An oral presentation of results presented
herein was given at the 23rd ESICM
congress, Barcelona, Oct 2010, and a
congress abstract was published in Intensive
Care Medicine (36:S203–S203, 2010). This
abstract was also presented at the 31st SSAI
conference, Bergen, June 2011. Results
from a sub-study on the effect of
clopidogrel during TH have been published
in Resuscitation
(doi:10.1016/j.resuscitation.2010.07.002).
Electronic supplementary material
The online version of this article
(doi:10.1007/s00134-012-2540-1) contains
supplementary material, which is available
to authorized users.
T. W. Bjelland ()) Á O. Dale Á
B. O. Haugen Á P. Klepstad
Department of Circulation and Medical
Imaging, Faculty of Medicine, Norwegian
University of Science and Technology,
7491 Trondheim, Norway
e-mail: thor.w.bjelland@ntnu.no
Tel.: ?47-72-576970
Fax: ?47-72-826028
B. O. Haugen
Department of Cardiology, St Olavs
Hospital, 7006 Trondheim, Norway
K. Kaisen Á K. Strand
Department of Anaesthesiology and
Intensive Care, Stavanger University
Hospital, 4011 Stavanger, Norway
S. Lydersen
Unit for Applied Clinical Research,
Norwegian University of Science and
Technology, 7491 Trondheim, Norway
Abstract Purpose: To compare
two protocols for sedation and anal-
gesia during therapeutic
hypothermia: midazolam and fenta-
nyl versus propofol and remifentanil.
The primary outcome was the time
from discontinuation of infusions to
extubation or decision not to extu-
bate (offset time). Secondary
outcomes were blood pressure, heart
rate, use of vasopressors and
inotropic drugs, pneumonia and neu-
rological outcome. Methods: This
was an open, randomised, controlled
trial on 59 patients treated with
therapeutic hypothermia (33–34 °C
for 24 h) after cardiac arrest in two
Norwegian university hospitals
between April 2008 and May 2009.
The intervention was random allo-
cation to sedation and analgesia with
fentanyl. Baseline characteristics
were similar. Sedation and analgesia
were stopped in 35 patients, and
extubation was performed in 17 of
these. Sedation had to be continued
for 24 patients. Time to offset was
significantly lower in patients given
propofol and remifentanil [mean
(95 % confidence intervals) 13.2
(2.3–24) vs. 36.8 (28.5–45.1) h,
respectively, p 0.001]. Patients
given propofol and remifentanil
needed norepinephrine infusions
twice as often (23 vs. 12 patients,
p = 0.003). Incidence of pneumonia
and 3-month neurological outcome
were similar in the two groups.
Conclusions: Time to offset was
significantly shorter in patients trea-
ted with propofol and remifentanil.
However, the clinical course in 40 %
of patients prevented discontinuation
of sedation and potential benefits
from a faster recovery. The propofol
and remifentanil group required
norepinephrine twice as often, but
both protocols were tolerated in most
patients.
Keywords Induced hypothermia Á
Heart arrest Á Coma Á Deep sedation Á
Analgesia Á Clinical pharmacology
Abbreviations
Intensive Care Med (2012) 38:959–967
DOI 10.1007/s00134-012-2540-1 ORIGINAL
Our finding of a faster offset in the PR group agrees
with previous studies on other ICU patients. Muellejans
et al. [19] reported a shorter time to extubation with
remifentanil and additional propofol than with midazolam
and fentanyl (2.2 vs. 5.7 h, respectively). Bauer et al. [20]
reported a mean time to extubation of 0.8 and 8 h in
patients g
different
sufentanil
also assoc
contrast t
no differe
The d
the prim
be explai
analgesic
hypotherm
increase b
tion phar
volunteer
clearance
perature
serum con
TH [31].
decreased
action red
bation [32
doses of s
cially dur
of awaren
ative over
drugs wit
The ti
ever, in
analgesia
20 400 10 30 50
0.00.20.40.60.81.0
X
X X XX
X
XX
X XX
Hours from cessation of sedation
Proportionextubated
p < 0.001
X
Propofol and remifentanil
Midazolam and fentanyl
Outcome censored
Fig. 2 Kaplan–Meier plot of consciousness recovery time defined
as the time to extubation or decision not to extubate. X = decision
not to extubate. Time to extubation in such cases remains unknown
(i.e. outcome is censored). p value calculated with log-rank test
Table 3 Circulatory variables and need for circulatory support during the first
Characteristics Hypothermia
Propofol and
remifentanil
Midazolam
and fentanyl
p
Mean arterial pressure (mmHg) 74 (6) 76 (4) 0
Systolic blood pressure (mmHg) 107 (9) 107 (8) 0
Diastolic blood pressure (mmHg) 60 (5) 60 (3) 0
Heart rate (beats/min) 55 (7) 66 (11) 0
Total fluid balance (mL/h)
Number of vasopressor or inotropic
infusions
1.0 (0.5) 1.0 (0.9) 0
Norepinephrine dose (lg/kg/min), n 0.073 (0.05),
22
0.083 (0.05),
11
0
Adrenaline dose (lg/kg/min), n 0a
0a
Dopamine dose (lg/kg/min), n 3.7 (2.3), 12 4.2 (1.4), 11 0
Dobutamine dose (lg/kg/min), n 0a
5a
Levosimendan dose (lg/kg/min), n 2a
3a
Arterial pH 7.4 (0.1) 7.4 (0.1) 0
Blood lactate (mmol/L) 1.3 (0.6) 1.8 (0.5) 0
964
Our finding of a faster offset in the PR group agrees
with previous studies on other ICU patients. Muellejans
et al. [19] reported a shorter time to extubation with
remifentanil and additional propofol than with midazolam
and fentanyl (2.2 vs. 5.7 h, respectively). Bauer et al. [20]
reported a mean time to extubation of 0.8 and 8 h in
tion pharmacokinetic modelling of data from human
volunteers predicted an 11.1 % decrease in midazolam
clearance for each degree Celsius reduction in core tem-
perature [30]. In patients with traumatic brain injuries,
serum concentrations of midazolam were elevated during
TH [31]. Elimination of propofol and remifentanil is
decreased during hypothermia, but their short duration of
action reduce the potential increase in the time to extu-
bation [32, 33]. Second, the patients may be given higher
doses of sedatives and analgesics than needed [34], espe-
cially during neuromuscular blockade because of concerns
of awareness. The impact on extubation time from a rel-
ative overdose of analgesics or sedatives is likely larger for
drugs with a longer duration of action.
The time to offset was shorter in PR patients. How-
ever, in 24 patients discontinuation of sedation and
analgesia could not be performed because of respiratory
20 400 10 30 50
0.0
X
Hours from cessation of sedation
X
Propofol and remifentanil
Midazolam and fentanyl
Outcome censored
Fig. 2 Kaplan–Meier plot of consciousness recovery time defined
as the time to extubation or decision not to extubate. X = decision
not to extubate. Time to extubation in such cases remains unknown
(i.e. outcome is censored). p value calculated with log-rank test
Table 3 Circulatory variables and need for circulatory support during the first 48 h of study protocol treatment
Characteristics Hypothermia Total study period
Propofol and
remifentanil
Midazolam
and fentanyl
p value Propofol and
remifentanil
Midazolam
and fentanyl
p value
Mean arterial pressure (mmHg) 74 (6) 76 (4) 0.69 72 (4) 75 (5) 0.69
Systolic blood pressure (mmHg) 107 (9) 107 (8) 0.82 103 (7) 106 (9) 0.86
Diastolic blood pressure (mmHg) 60 (5) 60 (3) 0.71 58 (4) 59 (3) 0.59
Heart rate (beats/min) 55 (7) 66 (11) 0.07 62 (7) 70 (10) 0.06
Total fluid balance (mL/h) 184 (47) 133 (49) 0.25
Number of vasopressor or inotropic
infusions
1.0 (0.5) 1.0 (0.9) 0.12 1.0 (0.5) 1.0 (1.0)
Norepinephrine dose (lg/kg/min), n 0.073 (0.05),
22
0.083 (0.05),
11
0.61,
0.003
0.107 (0.06),
23
0.081 (0.05),
12
0.23,
0.003
Adrenaline dose (lg/kg/min), n 0a
0a
1a
1a
Dopamine dose (lg/kg/min), n 3.7 (2.3), 12 4.2 (1.4), 11 0.79, 0.76 5.0 (2.1), 13 5.4 (1.5), 11 0.95, 0.70
Dobutamine dose (lg/kg/min), n 0a
5a
1a
5a
Levosimendan dose (lg/kg/min), n 2a
3a
3a
3a
Arterial pH 7.4 (0.1) 7.4 (0.1) 0.40 7.4 (0.0) 7.4 (0.0) 0.64
Blood lactate (mmol/L) 1.3 (0.6) 1.8 (0.5) 0.12 1.5 (0.7) 1.7 (0.3) 0.32
Base excess -3.6 (2.2) -2.5 (1.2) 0.56 -4.0 (2.2) -2.3 (0.9) 0.12
Unless specified otherwise, all values obtained for each patient
during study drug infusion for up to 48 h were used. Hypothermia
is defined as period from first to last confirmed core tempera-
ture B34 °C. The mean of all measurements was used for each
patient. Average doses of vasopressors or inotropic drugs were
calculated for the duration of infusion. Net fluid balance was only
available for every 24-h period. Data are given as median (semi-
interquartile range) or number of observations. Unless specified
otherwise, Mann–Whitney U test was used for comparisons.
Dichotomous data were analysed with the unconditional z-pooled
test
a
Too few patients for statistical test
Propofol

bupurenorphine : morphine 25 40
6 9 morphine opioid
Pentazocine : 15mg 3 4
15 30mg

Drug Efficacy
Hypotensive
Effect
Sedative
Effecta
depending on type
of drug; e.g.
midazolam 2.5–10
mg)b
rewarming
fentanyl 50–100
␮g,b
alfentanyl
100–250 ␮g
Dexmedetomidine
50–100 ␮gb
Drug Efficacy
Hypotensive
Effect
Sedative
Effecta
depending on type
of drug; e.g.
midazolam 2.5–10
mg)b
rewarming
fentanyl 50–100
␮g,b
alfentanyl
100–250 ␮g
Dexmedetomidine
50–100 ␮gb
Ketanserin 10 mgb
fentanyl 50–100
␮g,b
alfentanyl
100–250 ␮g
Dexmedetomidine
50–100 ␮gb
Ketanserin 10 mgb
mg
Currently not available in the United States
Metamizol ϩ Ϫ Ϫ Low efficacy
Ondansetron ϩ Ϫ Ϯ Low efficacy
Other options:
lidocaine,
nalbuphine,
pentazocine,
methylphenidate
Ϫ/Ϯ Ϫ Ϫ Questionable or no efficacy
Muscle paralyzers ϩϩϩϩϩ Ϫ Ϫ Advantage: 100% effective. Disadvantages: does not
affect neurological triggers for shivering; may
mask insufficient sedation and/or seizure activity;
long-term risks of critical illness neuropathy
For most drugs efficacy increases at higher doses. Efficacy scale: Ϫ, not effective; ϩ, somewhat effective; ϩϩ, moderately effective; ϩϩϩ, effective;
ϩϩϩϩ, highly effective; ϩϩϩϩϩ, 100% effective. Side effect scale: Ϫ, no risk; ϩ, mild risk; ϩϩ, moderate risk; ϩϩϩ, clear risk; ϩϩϩϩ, high risk.
a
Having a sedative effect can be both advantageous (suppression of stress response, vasodilation with increased heat loss) and disadvantageous
morphine fentanyl

Drug Efficacy
Hypotensive
Effect
Sedative
Effecta
depending on type
of drug; e.g.
midazolam 2.5–10
mg)b
rewarming
fentanyl 50–100
␮g,b
alfentanyl
100–250 ␮g
Dexmedetomidine
50–100 ␮gb
mg
Currently not available in the United States
Metamizol ϩ Ϫ Ϫ Low efficacy
Ondansetron ϩ Ϫ Ϯ Low efficacy
Other options:
lidocaine,
nalbuphine,
pentazocine,
methylphenidate
Ϫ/Ϯ Ϫ Ϫ Questionable or no efficacy
Muscle paralyzers ϩϩϩϩϩ Ϫ Ϫ Advantage: 100% effective. Disadvantages: does not
affect neurological triggers for shivering; may
mask insufficient sedation and/or seizure activity;
long-term risks of critical illness neuropathy
For most drugs efficacy increases at higher doses. Efficacy scale: Ϫ, not effective; ϩ, somewhat effective; ϩϩ, moderately effective; ϩϩϩ, effective;
ϩϩϩϩ, highly effective; ϩϩϩϩϩ, 100% effective. Side effect scale: Ϫ, no risk; ϩ, mild risk; ϩϩ, moderate risk; ϩϩϩ, clear risk; ϩϩϩϩ, high risk.
a
Having a sedative effect can be both advantageous (suppression of stress response, vasodilation with increased heat loss) and disadvantageous
(complication of neurological evaluation, hypotension). Reduced metabolism during cooling can lead to drug accumulation with persistent sedative effect
after rewarming; this applies especially to longer-acting drugs such as benzodiazepines and morphine, where a persistent sedative effect can complicate
neurological evaluation; b
can also be given as continuous infusion. General methods: there is some evidence that warm-air skin counterwarming can be
used to combat shivering. Drugs such as acetamoinophen (paracetamol), buspirone, and/or nonsteroidal anti-inflammatory drugs can be used to lower the
shivering threshold.
1112 Crit Care Med 2009 Vol. 37, No. 3
: 100% .
:
critical illness neuropathy, myopathy

When Should Sedation or Neuromuscular Blockade
Be Used During Mechanical Ventilation?
Suzanne Bennett MD and William E Hurford MD
Introduction
The Triad of Agitation
Pain
Anxiety
Delirium
Deep Sedation and Anesthesia
Neuromuscular Blocking Agents
Summary
Sedation has become an important part of critical care practice in minimizing patient discomfort
and agitation during mechanical ventilation. Pain, anxiety, and delirium form a triad of factors that
can lead to agitation. Achieving and maintaining an optimal level of comfort and safety in the
intensive care unit plays an essential part in caring for critically ill patients. Sedatives, opioids, and
neuromuscular blocking agents are commonly used in the intensive care unit. The goal of therapy
should be directed toward a specific indication, not simply to provide restraint. Standard rating
scales and unit-based guidelines facilitate the proper use of sedation and neuromuscular blocking
Respir Care 2011;56(2):168 –176.

Chamorro C; Anesth Analg 2010;110:1328-35
REFERENCES
1. Bernard SA, Gray TW, Buist MD, Jones BM, Si
Gutteridge G, Smith K. Treatment of comatose su
out-of-hospital cardiac arrest with induced hyp
N Engl J Med 2002;346:557–63
2. Hypothermia After Cardiac Arrest Study group. M
peutic hypothermia to improve the neurologic out
cardiac arrest. N Engl J Med 2002;346:549–56
3. Bernard SA, Buist M. Induced hypothermia in cr
medicine: a review. Crit Care Med 2003;31:2041–51
4. Polderman KH. Application of therapeutic hypother
ICU: opportunities and pitfalls of a promising trea
dality. Part 1: Indications and evidence. Intensive
2004;30:556–75
5. Holzer M, Bernard SA, Hachimi-Idrissi S, Roine RO
Mu¨llner M; Collaborative group on Induced Hypot
Neuroprotection After Cardiac Arrest. Hypothermi
roprotection after cardiac arrest: systematic review
vidual patient data meta-analysis. Crit Care M
33:414–8
6. Ramani R. Hypothermia for brain protection and res
Curr Opin Anaesthesiol 2006;19:487–91
7. Alzaga AG, Cerdan M, Varon J. Therapeutic hyp
Resuscitation 2006;70:369–80
8. Rincon F, Mayer SA. Therapeutic hypothermia for b
after cardiac arrest. Semin Neurol 2006;26:387–95
9. Howes D, Green R, Gray S, Stenstrom R, Easton D;
Association of Emergency Physicians. Evidence for
hypothermia after cardiac arrest. CJEM 2006;8:109–
10. Cheung KW, Green RS, Magee KD. Systematic
randomized controlled trials of therapeutic hypoth
neuroprotectant in post cardiac arrest patients. C
8:329–37
ICU: Intensive Care Unit. EEG: electroencephalographic monitoring. BIS: bispectral
index. TOF: Train-of-four. SR = suppression rate
Apply BIS sensor
Start remifentanil
6 µg/Kg/h
BIS value
under 40
BIS value
40-60
BIS value over
60 with SR
Ask for urgent EEG. If
electrical seizures or
status epilepticus, start
specific treatment
Start remifentanil 6
µg/Kg/h and lowest dose
propofol to maintain
values in this range
Post-cardiac arrest coma patient
admitted to ICU.
Start cisatracurium infusion at 0.1
mg/Kg/h after 0.1 mg/Kg of bolus.
After 12-24 h of treatment, discontinue hypothermia and
allow a slow controlled rewarming. At 36º cancel
cisatracurium. When TOF>0.9 cancel propofol. Start a
slow decrease in the remifentanil infusion to permit
neurological evaluation
Aberrant EEG
waves or
disproportionately
high SR
percentage for
the BIS value
Figure 1. Algorithm for using therapeutic hypothermia to treat
postcardiac arrest coma patients admitted to intensive care.
NMBA
BIS
TOF: train of four
EEG

TOF: train-of-four
http://www.vm.a.u-tokyo.ac.jp/geka/research/anes/vecro/

Surface counter warming
Metabolic benefits of surface counter warming during therapeutic
temperature modulation*
Neeraj Badjatia, MD, MSc; Evangelia Strongilis, RD; Mary Prescutti, RN; Luis Fernandez, MD;
Andres Fernandez, MD; Manuel Buitrago, MD, PhD; J. Michael Schmidt, PhD; Stephan A. Mayer, MD, FCCM
With increasing use of ad-
vanced devices to con-
trol core body tempera-
ture, clinicians find it
maintaining goal temperature during
shivering (1–3). This is an integrated
thermoregulatory reflex triggered by a
core body temperature that is lower
rapidly inhibiting it when it occurs (10).
The use of a forced air warmer in the
recovery room can reduce the frequency
(11, 12) and impact (12) of postanaes-
Objective: To determine the impact of counter warming (CW)
with an air circulating blanket on shivering and metabolic profile
during therapeutic temperature modulation (TTM).
Design: A prospective observational study.
Setting: An 18-bed neurologic intensive care unit.
Patients: Fifty mechanically ventilated patients with brain injury
undergoing TTM with automated surface and intravascular devices.
Interventions: Fifty indirect calorimetry (IDC) measurements
with and without CW during TTM.
Measurements and Main Results: IDC was continuously per-
formed for 10–15 minutes at baseline with CW (phase I), off CW
(phase II), and again after the return of CW (phase III). Shivering
severity during each phase was scored on a scale of 0؊3 using the
Bedside Shivering Assessment Scale (BSAS). Resting energy expen-
diture (REE), oxygen consumption, and carbon dioxide production
were determined by IDC; 56% were women, with mean age 61 ؎ 15
years. At the time of IDC, 72% of patients had signs of shivering
(BSAS >0). All measures of basal metabolism increased after re-
moval of the air warming blanket (from phases I and II); REE in-
creased by 27% and oxygen consumption by 29% (both p < 0.002).
A one-point increase in baseline BSAS was noted in 55% (n ‫؍‬ 23/42)
of patients from phase I to phase II. In a multivariate analysis,
sedative use (p ‫؍‬ 0.03), baseline moderate to severe shivering (p ‫؍‬
0.04), and lower serum magnesium levels (p ‫؍‬ 0.01) were associated
with greater increases in REE between phase I and phase II of CW.
Phase III of CW was associated with a reversal in the increases in all
metabolic variables.
Conclusions: Surface CW provides beneficial control of shiv-
ering and improves the metabolic profile during TTM. (Crit Care
Med 2009; 37:1893–1897)
KEY WORDS: energy expenditure; hypothermia; normothermia;
shivering; indirect calorimetry; brain injury; counter warming
found that by covering the entire anterior
surface, sparing the neck and face, sur-
face CW is beneficial. This greater pro-
portion of surface warming likely had a
greater effect on the mean skin tempera-
ture and impact on the feedback to the
hypothalamic thermoregulatory centers.
Cheng et al (24) have shown that a linear
relationship exists between core temper-
ature and the average skin temperature
for the appearance of shivering in the
nonanesthetized patient. The threshold
temperature for shivering is equal to the
sum of 20% of the mean skin tempera-
ture and 80% of the core temperature.
Therefore, to inhibit shivering, the aver-
age skin temperature must be raised by at
least 4°C to be as efficient as a 1°C in-
crease in core temperature (24). Al-
though the surface warming device was
turned to the maximal temperature
setting of 43°C, we did not assess shiver-
ing the importance of finding additional
methods to control shivering.
An alternative, nonsedating regimen
would be to continue targeting the pe-
ripheral mechanisms of cutaneous vaso-
constriction or skeletal muscular activity.
Infusions of dantrolene have been shown
to reduce both the severity and threshold
for shivering (25); however, this may lead
to prolonged muscular weakness and in-
creased number of ventilator days, and
therefore, limit its usefulness.
Additional targeting of the cutaneous
vasoconstrictive response, however, may
still be possible with the intravenous ad-
ministration of magnesium. As seen in
this study and previous assessments of
shivering (1), hypomagnesemia is a risk
factor for not only baseline shivering but
also response to surface CW. Magnesium
at high doses reduces the shivering re-
sponse or increases the rate of achieving
This study was designed to address a
physiologic end point, and so the effect of
reducing shivering with CW as it relates
to clinical outcome was not measured.
Shivering and its counter measures may
impact on the outcome (1) in patients
undergoing TTM and should be incorpo-
rated into any prospective study of TTM.
CONCLUSION
Whole body surface CW during TTM
represents a simple, nonsedating method
to combat the metabolic impact of shiv-
ering. This technique, however, does not
provide adequate shiver control for all
patients. Future studies should focus on
minimally sedating antishivering regi-
mens that can provide additional benefit
when surface CW fails.
1896 Crit Care Med 2009 Vol. 37, No. 6

Bedside Shivering Assessment Scale
Score
0
1
2 /
3
4
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): 3242-3247. doi:10.1161/STROKEAHA .108.523-654.

RESEARCH ARTICLE
Dexmedetomidine Reduces Shivering during
Mild Hypothermia in Waking Subjects
Clifton W. Callaway1
, Jonathan Elmer1,2
, Francis X. Guyette1
, Bradley J. Molyneaux2
,
Kacey B. Anderson3
, Philip E. Empey3
, Stacy J. Gerstel1
, Kate Holquist1
, Melissa
J. Repine1
, Jon C. Rittenberger1
*
1 Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh,
PA, United States of America, 2 Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh,
PA, United States of America, 3 School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
of America
* rittjc@upmc.edu
Abstract
Background and Purpose
Reducing body temperature can prolong tolerance to ischemic injury such as stroke or myo-
cardial infarction, but is difficult and uncomfortable in awake patients because of shivering.
We tested the efficacy and safety of the alpha-2-adrenergic agonist dexmedetomidine for
suppressing shivering induced by a rapid infusion of cold intravenous fluids.
Methods
Ten subjects received a rapid intravenous infusion of two liters of cold (4°C) isotonic saline
on two separate test days, and we measured their core body temperature, shivering, hemo-
dynamics and sedation for two hours. On one test day, fluid infusion was preceded by pla-
cebo infusion. On the other test day, fluid infusion was preceded by 1.0 μg/kg bolus of
dexmedetomidine over 10 minutes.
Results
All ten subjects experienced shivering on placebo days, with shivering beginning at a mean
(SD) temperature of 36.6 (0.3)°C. The mean lowest temperature after placebo was 36.0
(0.3)°C (range 35.7-36.5°C). Only 3/10 subjects shivered on dexmedetomidine days, and
the mean lowest temperature was 35.7 (0.4)°C (range 35.0-36.3°C). Temperature remained
below 36°C for the full two hours in 6/10 subjects. After dexmedetomidine, subjects had
moderate sedation and a mean 26 (13) mmHg reduction in blood pressure that resolved
within 90 minutes. Heart rate declined a mean 23 (11) bpm after both placebo and dexme-
detomidine. Dexmedetomidine produced no respiratory depression.
Conclusion
Dexmedetomidine decreases shivering in normal volunteers. This effect is associated with
a11111
OPEN ACCESS
Citation: Callaway CW, Elmer J, Guyette FX,
Molyneaux BJ, Anderson KB, Empey PE, et al.
(2015) Dexmedetomidine Reduces Shivering during
Mild Hypothermia in Waking Subjects. PLoS ONE
10(8): e0129709. doi:10.1371/journal.pone.0129709
Editor: Chiara Lazzeri, Azienda Ospedaliero-
Universitaria Careggi, ITALY
Received: January 13, 2015
Accepted: May 12, 2015
Published: August 3, 2015
Copyright: © 2015 Callaway et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.
Data Availability Statement: Data for the
manuscript are available at https://zenodo.org/record/
18489.
Funding: This work was supported by Pittsburgh
Emergency Medicine Foundation (www.pemf.net)
(JCR), and National Heart, Lung and Blood Institute -
NHLBI 5K12HL109068 (http://www.nhlbi.nih.gov/
research/training/emergency-med-k12) (JE). The
funders had no role in study design, data collection
Fig 1. Dexmedetomidine suppresses the shiver threshold through moderate sedation, no shivering and improved comfort. Compared to saline
infusion (circles), dexmedetomidine infusion allowed a more prolonged reduction in core temperature (A), with moderate sedation (B), no shivering (C), and
slight improvement in comfort (D). Figures depict mean with SD of temperature, median with range for sedation, and median with interquartile range for
shivering and comfort scales.
doi:10.1371/journal.pone.0129709.g001
Dexmedetomidine Reduces Shivering during Hypothermia

RESEARCH ARTICLE
Dexmedetomidine Reduces Shivering during
Mild Hypothermia in Waking Subjects
Clifton W. Callaway1
, Jonathan Elmer1,2
, Francis X. Guyette1
, Bradley J. Molyneaux2
,
Kacey B. Anderson3
, Philip E. Empey3
, Stacy J. Gerstel1
, Kate Holquist1
, Melissa
J. Repine1
, Jon C. Rittenberger1
*
1 Applied Physiology Laboratory, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh,
PA, United States of America, 2 Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh,
PA, United States of America, 3 School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
of America
* rittjc@upmc.edu
Abstract
Background and Purpose
Reducing body temperature can prolong tolerance to ischemic injury such as stroke or myo-
cardial infarction, but is difficult and uncomfortable in awake patients because of shivering.
We tested the efficacy and safety of the alpha-2-adrenergic agonist dexmedetomidine for
suppressing shivering induced by a rapid infusion of cold intravenous fluids.
Methods
Ten subjects received a rapid intravenous infusion of two liters of cold (4°C) isotonic saline
on two separate test days, and we measured their core body temperature, shivering, hemo-
dynamics and sedation for two hours. On one test day, fluid infusion was preceded by pla-
cebo infusion. On the other test day, fluid infusion was preceded by 1.0 μg/kg bolus of
dexmedetomidine over 10 minutes.
Results
All ten subjects experienced shivering on placebo days, with shivering beginning at a mean
(SD) temperature of 36.6 (0.3)°C. The mean lowest temperature after placebo was 36.0
(0.3)°C (range 35.7-36.5°C). Only 3/10 subjects shivered on dexmedetomidine days, and
the mean lowest temperature was 35.7 (0.4)°C (range 35.0-36.3°C). Temperature remained
below 36°C for the full two hours in 6/10 subjects. After dexmedetomidine, subjects had
moderate sedation and a mean 26 (13) mmHg reduction in blood pressure that resolved
within 90 minutes. Heart rate declined a mean 23 (11) bpm after both placebo and dexme-
detomidine. Dexmedetomidine produced no respiratory depression.
Conclusion
Dexmedetomidine decreases shivering in normal volunteers. This effect is associated with
a11111
OPEN ACCESS
Citation: Callaway CW, Elmer J, Guyette FX,
Molyneaux BJ, Anderson KB, Empey PE, et al.
(2015) Dexmedetomidine Reduces Shivering during
Mild Hypothermia in Waking Subjects. PLoS ONE
10(8): e0129709. doi:10.1371/journal.pone.0129709
Editor: Chiara Lazzeri, Azienda Ospedaliero-
Universitaria Careggi, ITALY
Received: January 13, 2015
Accepted: May 12, 2015
Published: August 3, 2015
Copyright: © 2015 Callaway et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.
Data Availability Statement: Data for the
manuscript are available at https://zenodo.org/record/
18489.
Funding: This work was supported by Pittsburgh
Emergency Medicine Foundation (www.pemf.net)
(JCR), and National Heart, Lung and Blood Institute -
NHLBI 5K12HL109068 (http://www.nhlbi.nih.gov/
research/training/emergency-med-k12) (JE). The
funders had no role in study design, data collection
Heart rate (Drug, p <0.001), SBP (Drug, p<0.001), diastolic blood pressure (Drug,
p<0.001), and respiratory rate (Drug, p<0.001) changed over time (Fig 2). The maximum
reduction in SBP relative to baseline was greater (mean difference (95% confidence interval) =
26 (17–34) mmHg) after dexmedetomidine than after placebo (8 (2–15) mmHg) (t = 6.97;
p = 0.0001). The maximum reduction in diastolic blood pressure (19 (9–27) mmHg and 14 (6–
21) mmHg) and heart rate (23 (16–30) bpm and 25 (16–34) bpm) did not differ between dex-
medetomidine and placebo days. Heart rate and blood pressure increased slightly during cold
fluid administration in the placebo group. End-tidal CO2 did not differ between drug groups
and did not vary over time. The lowest recorded SpO2 was lower after dexmedetomidine
(median, IQR = 95.5%, 95–96%) than after placebo (97%, 96–97%) (p = 0.02).
Sedation (RASS<0) was evident in 9 of 10 subjects after dexmedetomidine (RASS from -1
to -3) and in 0 of 10 subjects after placebo. The total RASS (p = 0.0076) and lowest RASS
(p = 0.0068) were lower after dexmedetomidine. Several subjects snored while sleeping, but no
Fig 2. Dexmedetomidine infusion lowered SBP (A) and heart rate (B). In (A) systolic blood pressure is depicted in solid lines and symbols, while diastolic
blood pressure is depicted in gray lines and symbols. End-tidal CO2 did not differ between groups (C). Pulse oximetry determined SpO2 was lower with
dexmedetomidine, though the magnitude of the reduction was not clinically important (D). Figures depict mean with SD for blood pressure, heart rate and end
tidal CO2. Median and range for SpO2 is depicted.
doi:10.1371/journal.pone.0129709.g002

650mg 4
Mg 4g 3-4 mg/dl)
/
Dexmedetomidine 0.2mcg/kg/hr
/
Fentanyl 25mcg/hr
Propofol
Midazolam
BSAS 1
BSAS 1
BSAS 1
BSAS: Bedside Shivering Assessment Scale
NeurocriLcal care. 2015 Dec;23 Suppl 2;S48-68. doi: 10.1007/s12028-015-0158-1.

α
Hydra azine
Dexmedetomidine
Droperidor Chlorpromazine
α
↓

36.5°C
≤ 0.25 °C/hr
↑K
↓
• 37.5°C
• 37.8°C : 0.5 – 1.0 L

℃
39
38
37
36
35
34
33
32
0.1℃/hr
24 48
32-36℃
ROSC
4
TTM

ROSC
ROSC
•
•
Intensive Care Med (1987) 13:244-248
Intensive
Care Medicine
© Springer-Verlag 1987
Original articles
The neurologic effects of thiopental therapy after cardiac arrest
E Monsalve, L. Rucabado, M. Ruano, J. Cufiat, V. Lacueva and A. Vifiuales
IntensiveCareUnit, Hospital La Fe, Valencia,Spain
Received: 16 June 1985;accepted: 17 September1986

PCAS
•
– Generalized Convulsive Status Epileptics: GCSE
5
5
•
– Non-convulsive Status Epileptics: NCSE
• Absence seizures
• Complex partial seizures

NCSE
ntinuous electroencepha-
G) recording in a 70-yr-old
ecent aortic valve repair
ered mental status in the
nsive care unit (ICU). A,
reveals nonconvulsive
pticus with generalized
discharges at 3 Hz. B,
iform discharges were
ter the patient was given
mg IV.
eria for Nonconvulsive Seizurea
eria
Lorazepam 1mg
Continuous Electroencephalogram Monitoring in the Intensive Care Unit
Anesth Analg 2009;109:506–23

REVIEW
Guidelines for the Evaluation and Management of Status
Epilepticus
Gretchen M. Brophy • Rodney Bell • Jan Claassen • Brian Alldredge •
Thomas P. Bleck • Tracy Glauser • Suzette M. LaRoche • James J. Riviello Jr. •
Lori Shutter • Michael R. Sperling • David M. Treiman • Paul M. Vespa •
Neurocritical Care Society Status Epilepticus Guideline Writing Committee
Published online: 24 April 2012
Ó Springer Science+Business Media, LLC 2012
Abstract Status epilepticus (SE) treatment strategies
vary substantially from one institution to another due to the
lack of data to support one treatment over another. To
provide guidance for the acute treatment of SE in critically
ill patients, the Neurocritical Care Society organized a
writing committee to evaluate the literature and develop an
evidence-based and expert consensus practice guideline.
Literature searches were conducted using PubMed and
studies meeting the criteria established by the writing
committee were evaluated. Recommendations were
developed based on the literature using standardized
assessment methods from the American Heart Association
and Grading of Recommendations Assessment, Develop-
ment, and Evaluation systems, as well as expert opinion
when sufﬁcient data were lacking.
Keywords Status epilepticus Á Seizure Á Guideli
EEG Á Antiepileptic treatment
Introduction
Status epilepticus (SE) requires emergent, target
ment to reduce patient morbidity and m
Controversies about how and when to treat SE ha
described in the literature [1–3]. The Neurocriti
Society Status Epilepticus Guideline Writing Co
was established in 2008 to develop evidence-base
consensus guidelines for diagnosing and managing
chairs were selected by the Neurocritical Care
with ten additional neurointensivists and epilep
from across the United States included on the co
After the committee prepared an initial set of g
Neurocrit Care (2012) 17:3–23
DOI 10.1007/s12028-012-9695-z
Neurocrit Care (2012) 17:3–23
continued dosing for maintenance therapy. For patients
who fail emergent initial therapy, the goal of urgent control
therapeutic level requires selection of an intravenously
administered compound. In patients with known epilepsy
Table 6 Treatment recommendations for SE
Treatment Class/level of evidence References
Emergent treatment
Lorazepam Class I, level A [19, 30, 52, 83, 87–98]
Midazolam Class I, level A [84, 99–108]
Diazepam Class IIa, level A [30, 87, 90, 95, 97–105, 107, 109–114]
Phenytoin/fosphenytoin Class IIb, level A [30, 87, 94, 115–119]
Phenobarbital Class IIb, level A [30, 87, 114]
Valproate sodium Class IIb, level A [116, 117, 120–122]
Levetiracetam Class IIb, level C [119, 123–130]
Urgent treatment
Valproate sodium Class IIa, level A [117, 120–122, 131–136]
Phenytoin/fosphenytoin Class IIa, level B [30, 87, 97, 107, 114, 115, 117, 119, 132, 133, 137]
Midazolam (continuous infusion) Class IIb, level B [106]
Phenobarbital Class IIb, level C [138, 139]
Levetiracetam Class IIb, level C [119, 123, 125–127, 129, 133, 140, 141]
Refractory treatment
Midazolam Class IIa, level B [28, 106–108, 142–150]
Propofol Class IIb, level B [26, 36, 62, 66, 68, 144, 151–155]
Pentobarbital/thiopental Class IIb, level B [26, 27, 56, 58, 59, 62, 63, 66, 68, 107, 115, 139, 154, 156–158]
Valproate sodium Class IIa, level B [120, 121, 131, 136, 159–161]
Levetiracetam Class IIb, level C [37, 66, 125–127, 129, 140, 141, 159, 162–164]
Phenytoin/fosphenytoin Class IIb, level C [57, 165]
Lacosamide Class IIb, level C [166–168]
Topiramate Class IIb, level C [169]
Phenobarbital Class IIb, level C [138]
10 Neurocrit Care (2012) 17:3–23
Lorazapam
Na

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