Please consult package insert for more detailed safety information and instructions for use. BMD/AS50/0516/0115

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2 Indications for Use: The ARCTIC SUN Temperature Management System is a thermal regulating system, indicated for monitoring and controlling patient temperature in adult and pediatric patients of all ages. Contraindications There are no known contraindications for the use of a non-invasive thermoregulatory system. Do not place ARCTICGEL Pads on skin that has signs of ulcerations, burns, hives or rash. Do not remove the fabric release liner of the Neonatal ARCTICGEL Pad and expose the hydrogel. Do not place ARCTICGEL Pads on immature (non-keratinized) skin or premature babies. While there are no known allergies to hydrogel materials, caution should be exercised with any patient with a history of skin allergies or sensitivities. Warnings When using the ARCTIC SUN Temperature Management System, note that all other thermal conductive systems, in use while warming or cooling with this device may interfere with patient temperature control. Cautions Due to underlying medical or physiological conditions, some patients are more susceptible to skin damage from pressure and heat or cold. Patients at risk include those with poor tissue perfusion or poor skin integrity due to edema, diabetes, peripheral vascular disease, poor nutritional status, steroid use or high dose vasopressor therapy. Examine the patient s skin under the ARCTICGEL Pads. Skin injury may occur as a cumulative result of pressure, time and temperature. Carefully remove ARCTICGEL Pads from the patient s skin at the completion of use. Aggressive removal or removal of cold pads from the patient s skin may result in skin tears. The rate of temperature change and potentially the final achievable patient temperature is affected by many factors. Treatment application, monitoring and results are the responsibility of the attending physician. If the patient does not reach target temperature in a reasonable time or the patient is not able to be maintained at the target temperature, the skin may be exposed to low or high water temperatures for an extended period of time which may increase the risk for skin injury. Please consult package insert for more detailed safety information and instructions for use.

3 Disclosure Product Training and Education: Any discussion regarding BARD products during this presentation is limited to information that is consistent with BARD labeling for these products.

4 Learning Objectives Upon completion of this module, the participant will be able to: Recognize role of Targeted Temperature Management (TTM) Review TTM evidence-based practice Discuss patient management during TTM Identifying and addressing shivering Fever control

5 Why are we here today?

6 Pathophysiology

7 Global Ischemia Transient (5 30 minutes) complete or nearly complete lack of blood flow Lack of blood supply leads to ischemia If blood flow is not restored within 30 minutes, widespread necrosis occurs Polderman, KH. (2004). Int Care Med. 30(4),

8 Focal Ischemia Results from occlusion of a single cerebral blood vessel Necrosis occurs near the occluded vessel if reperfusion does not occur within 60 min Surrounding area (penumbra) may be salvaged if reperfusion occurs Polderman, KH. (2004). Int Care Med. 30(4),

9 Neuronal Damage from Ischemia Complex negative cascade of reactions at cellular level May begin minutes after injury and continue up to 72 hours or longer Chain of events is called secondary injury or reperfusion injury Polderman, KH. (2008). Lancet. 371,

10 Ischemic Cascade 1-3 Mitochondrial dysfunction Release of excitatory neurotransmitter glutamate Excess release of calcium Disruption of cell membranes Free radical production Blood brain barrier dysfunction 1. Polderman, KH. (2008). Lancet. 371, Lee, K (2012). The NeuroICU Book. New York: McGraw Hill Companies, Inc. p Malhotra, R. & Lee, K. (2012). The Neuro ICU Book. New York: McGraw Hill Companies, Inc. pp

11 Alkadri, M. (2009). The Ochsner Journal. 9(4),

12 preventing ischemic injury is central to all neuroprotective strategies Polderman, KH. (2008). Lancet. 371,

13 Targeted Temperature and Patient Management

14 Targeted Temperature Management (TTM) Prescribed TTM includes dosage and duration Current trends based on recent studies 33 C - 36 C selected and achieved 36 C Hyperthermia control Nielsen, N. et al. (2013). N Engl J Med. 369(23),

15 Key Clinical Considerations* Inhibit neurotransmitter release 1 Inhibit free radical production 1 Reduce oxygen consumption 1 Decrease cerebral metabolic rate (5-8% for every 1 C) 1 Preserve blood brain barrier integrity 1 Consider the shivering threshold: dependent on patient s thermoregulatory set point 1,2 Consider the reduction in cerebral metabolic demand 1 May be appropriate for patient population that cannot tolerate 33 C 3 ICP and cerebral edema are decreased 2 1. Polderman, KH. (2008). Lancet. 371, Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp Nielsen, N. et al. (2013). N Engl J Med. 369(23), *Follow physician orders and / or your hospital s policies and procedures for selecting target temperature

16 Key Clinical Considerations Hyperthermia Hyperthermia control with targeted temperature management in either the hypothermic or normothermic mode Occurs in 20 50% of critically ill neurologic patients Independently associated with increased morbidity and mortality Mayer SA, et al (2004). Crit Care Med. 32(12),

17 Four Phases * 37 C 37 C Normothermia Induction Rewarm 0.25 C / hour 32 C 34 C Maintenance hours 32 C 34 C *Duration to follow institutional and society guidelines Nielsen, N. et al. (2013). N Engl J Med. 369(23),

18 Four Phases * 72hrs Controlled Normothermia 37 C Induction Rewarm 37 C Normothermia 36 C Maintenance 36hrs of Intervention 36 C 0.5 C / hour 4+ Day Protocol *Duration to follow institutional and society guidelines Nielsen, N. et al. (2013). N Engl J Med. 369(23),

19 Four Phases * Time to Initiation 37 C 37 C Normothermia Induction Rewarm 0.25 C / 16hrs 32 C 36 C Maintenance 24 hours *Duration to follow institutional and society guidelines Nielsen, N. et al. (2013). N Engl J Med. 369(23),

20 What s the latest news in the TTM field? 2010 Comatose adult patients with ROSC should be cooled to 32 C to 34 C for 12 to 24 hours Field, JM. et al (2010). Circulation. 122(18): S640-S664.

21 What s the latest news in the TTM field? 2010 Comatose adult patients with ROSC should be cooled to 32 C to 34 C for 12 to 24 hours 2015 All comatose adult patients with ROSC should have TTM 1. Field, JM. et al (2010). Circulation. 122(18): S640-S Neumar, RW. et al (2015). Circulation. 132: S313-S367.

22 What s the latest news in the TTM field? 2010 Comatose adult patients with ROSC should be cooled to 32 C to 34 C for 12 to 24 hours 2015 All comatose adult patients with ROSC should have TTM, with a target temperature between 32 C and 36 C selected and achieved 1. Field, JM. et al (2010). Circulation. 122(18): S640-S Neumar, RW. et al (2015). Circulation. 132: S313-S367.

23 What s the latest news in the TTM field? 2010 Comatose adult patients with ROSC should be cooled to 32 C to 34 C for 12 to 24 hours 2015 All comatose adult patients with ROSC should have TTM, with a target temperature between 32 C and 36 C selected and achieved, then maintained constantly for 24 hours 1. Field, JM. et al (2010). Circulation. 122(18): S640-S Neumar, RW. et al (2015). Circulation. 132: S313-S367.

24 What s the latest news in the TTM field? Select and Maintain Specific conditions of the patient may favor selection of one temperature over another Allowing patients to warm above 36 C would be inconsistent with current TTM recommendations Neumar, RW. et al (2015). Circulation. 132: S313-S367.

25 What s the latest news in the TTM field? Prehospital Initiation Routine prehospital cooling of patients after ROSC with rapid infusion of cold intravenous fluids is no longer recommended Neumar, RW. et al (2015). Circulation. 132: S313-S367.

26 What s the latest news in the TTM field? Actively Preventing Fever Fever has the potential of worsening ischemic injury Actively preventing fever in comatose patients after TTM The simplest method to prolonged hyperthermia prevention may be to leave the devices / strategies used for TTM in place Neumar, RW. et al (2015). Circulation. 132: S313-S367.

27 Physiological Effects of Therapeutic Hypothermia * BP, HR, CO 1-3 EKG Changes Prolonged PR interval 1,2 Widening QRS complex 1,2 Increased QT wave 1,2 J or Osborn wave 1 Cardiovascular *Representative of target temperatures C 1. Mehta, S. (2010). PA: HMP Communications. pp Nunnally, ME. (2010). Mount Prospect: SCCM. pp Tischerman, SA. & Stertz, F. (2010). New York: Springer Science. pp

28 Physiological Effects of Therapeutic Hypothermia * Cardiovascular J Wave or Osborn Wave *Representative of target temperatures C Polderman K. (2009). Crit Care Med. 37(7), S

29 Physiological Effects of Therapeutic Hypothermia * Hematological 1 Renal Impaired clotting cascade Impaired platelet function: potential increase in bleeding risk Decreased WBC count Diuresis 2,4 Electrolyte loss 3 Gastrointestinal 1 *Representative of target temperatures C Impaired bowel function / motility 1. Mehta, S. (2010). PA: HMP Communications. pp Bader MK and Littlejohn LR (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp Nunnally, ME. (2010). Mount Prospect: SCCM. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

30 Physiological Effects of Therapeutic Hypothermia * Systemic O 2 consumption and CO 2 production 1,3 Left shift on oxyhemoglobin curve: O 2 is not readily released to the tissues 4 Lactic acidosis 4 Endocrine 1,3 Insulin secretion Immune suppression 1 Infection: wound infections and pneumonia Other 1 Shivering *Representative Drug metabolism of target temperatures prolonged C 1. Mehta, S. (2010). PA: HMP Communications. pp Bader MK and Littlejohn LR (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp Nunnally, ME. (2010). Mount Prospect: SCCM. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

31 Shivering A physiological reflex mechanism that occurs when the body needs to produce or maintain heat The primary center for shivering is found in the posterior hypothalamus Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp

32 Mayer, SA. & Sessler, DI. Eds. (2009). Boca Raton: Taylor & Francis Group, p. 5.

33 Shivering Involuntary sympathetic response to generate heat 4 Vasoconstriction Piloerection Leads to increased: 1-4 Metabolic rate Metabolic demand Oxygen consumption Carbon dioxide production 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp Lee, K (2012). The NeuroICU Book. New York: McGraw Hill Companies, Inc. p Nunnally, ME. (2010). Mount Prospect: SCCM. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

34 Shivering Management Counter warming is the first line therapy for shivering treatment 1 Sedation prevents increased metabolism 1 Paralytic agents affect shivering 1-3 Precautions: difficult to identify seizures, select agent with anticonvulsant properties, continuous EEG may be utilized, drug metabolism is affected, appropriate dosing must be tailored to the specific conditions of the patients and must be tightly monitored 1. Mehta, S. (2010). PA: HMP Communications. pp Nunnally, ME. (2010). Mount Prospect: SCCM. pp Lee, K (2012). The NeuroICU Book. New York: McGraw Hill Companies, Inc. p. 192.

35 Phases of Therapy Induction Phase Careful monitoring of fluid balance Glucose control Monitor for hypertension Electrolyte management Prevention of shivering General Considerations: This list may vary depending on the patient s underlying condition. 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

36 Phases of Therapy Maintenance Phase Monitor for: EKG changes Bleeding Skin changes Maintain fluid status Infection surveillance Frequent electrolyte monitoring Avoid hyperglycemia General Considerations: This list may vary depending on the patient s underlying condition. 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp Mehta, S. (2010). PA: HMP Communications. pp Nunnally, ME. (2010). Mount Prospect: SCCM. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

37 Phases of Therapy Rewarming Phase Slow and controlled rewarming ( C per hour) Rapid rewarming may lead to: Hypoglycemia Increased ICP Rapid electrolyte shifts (hyperkalemia) Sudden vasodilation Cardiac arrest General Considerations: This list may vary depending on the patient s underlying condition. 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

38 Phases of Therapy Controlled Normothermia Phase Fever during the first 72 hours after ROSC has been associated with poor outcome Many clinicians attempt to maintain normothermia (36-37 C) during this time for at least 72 hours after ROSC General Considerations: This list may vary depending on the patient s underlying condition. Seder, DB. & Van der Kloot, TE. (2009). Crit Care Med. 37(7): S212.

39 Neuroprognostication TTM alters the ability to obtain a clinical neuro exam Drug clearance is decreased so sedatives may be present up to hours Decisions regarding withdrawal of care must be delayed until adequate clinical exam can be performed Follow your institution s guidelines for prognostication 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp Blondin, NA., & Greer, DM. (2011). The Neurologist. 17(5):

40 Controlled Normothermia

41 The Hypothalamus Plays a key role in temperature modulation 4 Set point is where the body will attempt to maintain temperature 4 This may be reset based on stimuli 4 Fever is one example of a shift in the set point 1,4 Damage to this structure may result in hyperthermia 2,3 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp Lee, K (2012). The NeuroICU Book. New York: McGraw Hill Companies, Inc. p Badjatia, N. (2012). The NeuroICU Book. New York, NY: McGraw Hill. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

42 Prevalence of Hyperthermia Defined as temperature > 38 C Occurs in up to 50% of all neurologically-injured patients What is your institution s definition of a fever? Mayer, SA. & Sessler, DI. Eds. (2009). Boca Raton: Taylor & Francis Group, p. 5.

43 Fever and Brain Injury Fever after trauma or ischemia may exacerbate damage from the original insult 2 Hyperthermia may worsen damage after focal and global ischemia 2 As high as 13% in metabolic rate associated with every 1 C in body temperature 1 1. Thompson HJ, Pinto-Martin J & Bullock MR. (2003). J Neurol Neurosug Psychiatry. 74: Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

44 Fever and Hemorrhage Intraventricular hemorrhage is a strong risk factor for fever development 3 A small amount of blood in CSF may induce fever 3,4 Fever has been associated with cerebral vasospasm Lee, K. (2012). The NeuroICU Book. New York: McGraw Hill Companies, Inc. p Patel, NC. et al (2010). Textbook of STEMI interventions. Malvern, PA: HMP Communications. pp Badjatia, N. (2012). The NeuroICU Book. New York, NY: McGraw Hill. pp Lenhardt, R. (2005). Therapeutic Hypothermia. Monticello, NY: Marcel Dekker.

45 Infectious and Non-Infectious Infectious Pneumonia Urinary Tract Infection Invasive Central Lines NG Tubes etc. Non-infectious Drugs, medications Sources of Fever Neurogenic or Central Fever resulting from damage to the thermoregulatory center in the hypothalamus Occurs in neurologically impaired patients Especially those with trauma or intracranial lesions 1. Thompson HJ, Pinto-Martin J & Bullock MR. (2003). J Neurol Neurosurg Psychiatry. 74: Childs, C. (2008). Br J Neurosurg. 22(4): Patel, NC. et al (2010). Textbook of STEMI interventions. Malvern, PA: HMP Communications. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp Nirula, R. & Gentilello, LM. (2005). Therapeutic Hypothermia. 4: Mayer, SA. & Sessler, DI. Eds. (2009). Boca Raton: Taylor & Francis Group, p Badjatia, N. (2012). The NeuroICU Book. New York, NY: McGraw Hill. pp Rossi et al. (2001). J Neurol Neurosurg Psych. 71: BMD/AS50/0516/0122

46 Understanding the Effects of Temperature Management

47 METABOLIC DEMAND C F

48 32% 28% 23% 19% 15% 11% 7% 4% 0% -3% -7% -11% -13% -16% -19% -22% -25% 41.0 C 40.5 C 40.0 C 39.5 C 39.0 C 38.5 C 38.0 C 37.5 C 37.0 C 36.5 C 36.0 C 35.3 C 35.0 C 34.5 C 34.0 C 33.5 C 33.0 C F F F F F F F 99.5 F 98.6 F 97.7 F 96.8 F 95.5 F 95.0 F 94.1 F 93.2 F 92.3 F 91.4 F

49 32% 41.0 C F 28% 23% 40.5 C 40.0 C F F UNCONTROLLED HYPERTHERMIA 19% 39.5 C F 15% 39.0 C F 11% 7% 38.5 C 38.0 C F F Increases Metabolic Demand 4% 0% 37.5 C 37.0 C 99.5 F 98.6 F Increases Risk of Cerebral Edema -3% 36.5 C 97.7 F -7% -11% 36.0 C 35.3 C 96.8 F 95.5 F Increases Length of Stay -13% 35.0 C 95.0 F -16% 34.5 C 94.1 F -19% 34.0 C 93.2 F -22% 33.5 C 92.3 F -25% 33.0 C 91.4 F

50 41.0 C 40.5 C 40.0 C 39.5 C 39.0 C 38.5 C 38.0 C 37.5 C 37.0 C 36.5 C 36.0 C 35.3 C 35.0 C 34.5 C 34.0 C 33.5 C 33.0 C F F F F F F F 99.5 F 98.6 F 97.7 F 96.8 F 95.5 F 95.0 F 94.1 F 93.2 F 92.3 F 91.4 F UNCONTROLLED HYPERTHERMIA 32% 28% 23% 19% 15% 11% 7% 4% 0% -3% -7% -11% -13% -16% -19% -22% -25%

51 41.0 C 40.5 C 40.0 C 39.5 C 39.0 C 38.5 C 38.0 C 37.5 C 37.0 C 36.5 C 36.0 C 35.3 C 35.0 C 34.5 C 34.0 C 33.5 C 33.0 C F F F F F F F 99.5 F 98.6 F 97.7 F 96.8 F 95.5 F 95.0 F 94.1 F 93.2 F 92.3 F 91.4 F UNCONTROLLED HYPERTHERMIA 32% 28% 23% 19% 15% 11% 7% 4% 0% -3% -7% -11% -13% -16% -19% -22% -25% Blankets / Wraps / Tylenol

52 41.0 C 40.5 C 40.0 C 39.5 C 39.0 C 38.5 C 38.0 C 37.5 C 37.0 C 36.5 C 36.0 C 35.3 C 35.0 C 34.5 C 34.0 C 33.5 C 33.0 C F F F F F F F 99.5 F 98.6 F 97.7 F 96.8 F 95.5 F 95.0 F 94.1 F 93.2 F 92.3 F 91.4 F UNCONTROLLED HYPERTHERMIA Blankets / Wraps / Tylenol 32% 28% 23% 19% 15% 11% 7% 4% 0% -3% -7% -11% -13% -16% -19% -22% -25% Uncontrolled Hyperthermia

53 32% 41.0 C F 28% 23% 40.5 C 40.0 C F F CONTROLLED NORMOTHERMIA 19% 15% 39.5 C 39.0 C F F ARCTIC SUN Temperature Management System 11% 7% 4% 38.5 C 38.0 C 37.5 C F F 99.5 F Uncontrolled Hyperthermia 0% 37.0 C 98.6 F -3% -7% -11% 36.5 C 36.0 C 35.3 C 97.7 F 96.8 F 95.5 F Blankets / Wraps / Tylenol -13% 35.0 C 95.0 F -16% 34.5 C 94.1 F -19% 34.0 C 93.2 F -22% 33.5 C 92.3 F -25% 33.0 C 91.4 F

54 32% 41.0 C F 28% 23% 40.5 C 40.0 C F F CONTROLLED NORMOTHERMIA 19% 15% 39.5 C 39.0 C F F ARCTIC SUN Temperature Management System 11% 7% 4% 0% 38.5 C 38.0 C 37.5 C 37.0 C F F 99.5 F 98.6 F Uncontrolled Hyperthermia Fever is Broken -3% -7% -11% 36.5 C 36.0 C 35.3 C 97.7 F 96.8 F 95.5 F Blankets / Wraps / Tylenol -13% 35.0 C 95.0 F -16% 34.5 C 94.1 F -19% 34.0 C 93.2 F -22% 33.5 C 92.3 F -25% 33.0 C 91.4 F

55 Uncontrolled Hyperthermia The Evidence Suggests Uncontrolled Hyperthermia Fever is Broken Blankets / Wraps / Tylenol

56 Uncontrolled Hyperthermia The Evidence Suggests Uncontrolled Hyperthermia Fever is Broken Blankets / Wraps / Tylenol

57 Overview of Cooling Methods Conventional 1,3 Antipyretic drugs Ice Fans IV saline infusions Water blankets Advanced 1-3 Non-invasive core cooling Intravascular Non-invasive core cooling with the ARCTIC SUN Temperature Management System 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO Saunders. pp Mehta, S. (2010). PA: HMP Communications. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

58 Core Precision with Advanced Surface Cooling ARCTICGEL Pads Targeted Temperature Management with Core Precision Three-layered construction LEAK PROOF Technology

59 Nursing Management for Fever When fever occurs, appropriate diagnostics are needed to ascertain possible etiology 2 Refractory fever >1-2hrs needs aggressive management 2 Institute shivering management strategies 2 Monitor for fever burden 1 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

60 Shivering Set point has been reset 2 Patients will shiver even when goal is normothermia 2 Assessment and control of shivering is imperative 1 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

61 Thresholds for Thermoregulatory Responses Mayer, SA. & Sessler, DI. Eds. (2009). Boca Raton: Taylor & Francis Group, p. 5.

62 Thresholds for Thermoregulatory Responses Neurogenic / Refractory Fever Elevated set point Interthreshold range remains constant when set points are shifted Mayer, SA. & Sessler, DI. Eds. (2009). Boca Raton: Taylor & Francis Group, p. 5.

63 Bedside Shivering Assessment Scale (BSAS) Scale Description 0 No Shivering 1 Mild Shivering, localized to neck and / or chest 2 Shivering, neck and / or chest and <2 extremities 3 Intermittent generalized shivering, >2 extremities Badjatia, N. et al (2008). Stroke. 39(12)

64 Counter Warming May reduce incidence of shivering 2 Tricks skin receptors into believing the body is warm 2 Warm air circulating may be used to cover these areas 1 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp

65 Summary It is important to properly manage patients receiving targeted temperature management You must be dedicated to shivering control in order to effectively cool patients or to maintain normothermia Fever in critically ill patients is associated with worse outcomes and length of stay

66 List of References Badjatia N (2006). Curr Neurol Neurosci Rep. 6(6): Badjatia NE, et al (2008). Stroke. 39(12): Choi A, et al (2010). Neurocrit Care. 14(3): Diringer MN, et al (2004). Crit Care Med. 32(7): English MJ & Hemmerling TM (2008). European J Anaesthesiology. 25(7): Greer DM, et al (2008). Stroke. 39: Mayer SA, et al (2004). Crit Care Med. 32(12): Merchant R (2006). Crit Care Med. 34(12): S490-S494. Nielsen N, et al (2013). N Engl J Med. 369(23): Peberdy, et al (2010) Circulation. 122(18 Suppl 3): S768-S786. Polderman K (2009). Crit Care Med. 37(7): S Tomte O, et al (2011). Crit Care Med. 39(3):