What is the role of medications in targeted temperature management (TTM)?

Updated: Jul 26, 2019
  • Author: Alex Koyfman, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

Answer

Note the following:

  • Patient comfort and sedation: Follow agitation and pain guidelines for the institution. Parenteral narcotic analgesia can be provided with morphine or fentanyl; sedation can be maintained with agents such as midazolam or propofol.

  • Paralysis to prevent shivering: Buspirone (serotonin 1A partial agonist) and meperidine appear to lower the shivering threshold. [43] Continuous pharmacologic neuromuscular blockade is usually required. Use of an endovascular technique along with buspirone and surface warming may avert shivering without the need for paralysis. [44]

  • The train-of-four method of monitoring neuromuscular blockade may not function properly when the patient is cold. Many patients can have paralytic agents discontinued once the target core body temperature is achieved. If shivering is observed, then the neuromuscular blocking agent needs to be resumed.

  • Cold saline infusion can be given via a peripheral line or femoral venous catheter to assist in achieving goal temperature. The infusion is 30 mL/kg of 4ºC normal saline over 30 minutes. This is not to be used via a jugular or subclavian line because the safety via this method is not yet known.

A 2018 open-label multicenter trial that evaluated the the effect of a continuous infusion of a neuromuscular blockade in 81 comatose OHCA patients treated with TTM found no reduction in lactate levels nor improvement in survival or neurologic outcome at hospital discharge. [45] However, the investigators noted the study may have been underpowered to detect clinical differences, and thus further research is needed.


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