Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations

ESICM/NACCS · 2024 · Europe

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Authors: Andrea Lavinio, Jonathan P Coles, Chiara Robba et al.
Title: Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations
Journal: Critical Care, 2024
DOI: 10.1186/s13054-024-04951-x
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC11107011

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Pathophysiology

Temperature measurement and control is an essential aspect of high-quality care in patients with severe traumatic brain injury (TBI)Level of consensus: Strong consensus (100%)
In patients with impending cerebral herniation, temperature control is essentialLevel of consensus: Strong consensus (89%)

Monitoring

Continuous temperature monitoring is preferable over intermittent temperature measurements in patients with severe TBILevel of consensus: Strong consensus (100%)
Monitoring core temperature (e.g., bladder, oesophageal, brain) is strongly recommended over measuring or monitoring superficial temperature (e.g., skin, tympanic) in severe TBILevel of consensus: Strong consensus (94%)
Monitoring brain temperature is recommended in addition to monitoring core systemic temperature as a therapeutic targetLevel of consensus: No consensus (61%)
When brain temperature monitoring is not immediately available, alternative sources of core temperature (oesophageal, bladder, intravascular) are acceptableLevel of consensus: Strong consensus (89%)
When brain temperature monitoring is in place, it is advisable to also assess core temperatureLevel of consensus: Strong consensus (100%)

ICP

Temperature control is a key component of intracranial pressure (ICP) management in severe TBI casesLevel of consensus: Strong consensus (100%)
Controlled normothermia (i.e., target core temperature 36.0–37.5 °C) should be included as an addition to the Tier 1 and Tier 2 treatments defined within the SIBICC 2019 guidelinesLevel of consensus: Moderate consensus (83%)
Therapeutic hypothermia (i.e., target core temperature ≤ 36.0 °C) should be considered in cases where tier 1 and 2 treatments (as per SIBICC guidance) have failed to control ICPLevel of consensus: Moderate consensus (83%)
If hypothermia is considered to control ICP, target temperature should be managed as close to physiological temperature as possibleLevel of consensus: Strong consensus (94%)
In patients with impending brain herniation, therapeutic hypothermia should be considered as a temporising strategy, and should be induced rapidlyLevel of consensus: No consensus (61%)
In patients with impending herniation awaiting surgical evacuation or decompression, the lowest target core temperature at which hypothermia should be initiated as a short-term temporising strategy isLevel of consensus: No consensusa (61%—35.0 °C; 17%—34.0 °C; 6%—33.0 °C; 17%—N/A)
In patients with exhausted intracranial volume buffering reserve and labile ICP with occasional spikes > 25 mmHg, the lowest target core temperature that a medium term ICP-control strategy should be implemented at isLevel of consensus: No consensusa (56%—35.0 °C; 33%—34.0 °C; 6%—33.0 °C; 6%—N/A)
In tier 3 treatment in SIBICC guidelines, before considering decompressive craniectomy, hypothermia (< 36.0 °C) should be attemptedLevel of consensus: No consensus (44%)
Before considering barbiturate burst suppression, hypothermia (< 36.0 °C) should be attemptedLevel of consensus: No consensus (61%)

Fever

Uncontrolled fever (neurogenic or secondary to inflammation or infection) can precipitate secondary brain injury in patients with severe TBILevel of consensus: Strong consensus (100%)
Fever control is recommended in patients with severe TBI who have seizures or are perceived to be at high risk of seizuresLevel of consensus: Strong consensus (94%)
Fever increases the risk of intracranial hypertension in patients with severe TBILevel of consensus: Strong consensus (94%)
Neurogenic fever (core temperature > 37.5 °C driven by neurological dysregulation in the absence of sepsis or clinically significant inflammatory process) is relatively common in traumatic brain injury cases, and it should be promptly detected and treated (i.e., with controlled normothermia targeting 36.0–37.5 °C), irrespective of ICPLevel of consensus: Moderate consensus (83%)
Controlled normothermia should be considered when pyrexia is secondary to sepsis or inflammatory processes, and when the patient is perceived to be at risk of secondary brain injury, especially in the acute phase of TBILevel of consensus: Strong consensus (94%)
In patients with severe TBI who are sedated and ventilated, controlled normothermia, irrespective of ICP, should be initiated reactively when fever is detectedLevel of consensus: Strong consensus (94%)
When neurogenic fever is detected in TBI cases, controlled normothermia should be continued for as long as the brain remains at risk of secondary brain damageLevel of consensus: Strong consensus (89%)

Hypothermic TTC induction

It is recommended that the rapid induction of hypothermia in TBI cases should be achieved with automated feedback-controlled temperature management devicesLevel of consensus: Strong consensus (89%)
It is advisable that neurotrauma ICUs should stock readily available NaCl solutions of different concentrations stored at ice-cold temperature for the management of intracranial hypertension crisesLevel of consensus: No consensus (50%)

TTC maintenance

An automated feedback-controlled TTC device that enables precise temperature control is desirable for the initiation of TTC and maintenance at target temperature in patients with severe TBILevel of consensus: Strong consensus (100%)
The maximum temperature variation that a patient should experience during normothermia is less than or equal to ± 0.5 °C per hour and ≤ 1 °C per 24-h periodLevel of consensus: Moderate consensus (78%)
When hypothermia is indicated, treatment should be continued for as long as the brain is considered to be at risk of secondary brain injuryLevel of consensus: Strong consensus (89%)

Rewarming following hypothermic TTC

Obtaining an interval scan and/or an alternative assessment of intracranial compliance, in addition to the absolute number of ICP, is recommended before rewarmingLevel of consensus: Strong consensus (89%)
When rewarming a patient from therapeutic hypothermia, rewarming should be controlled by an automated feedback-controlled TTC device and should not exceed 1.0 °C per 24-h periodLevel of consensus: No consensus (44%)
Rebound hyperthermia should be prevented whenever possible or promptly treated in cases when the brain is perceived to be at risk of secondary brain injuryLevel of consensus: Strong consensus (100%)

Shivering

It is important to assess, document and manage shivering in severe TBI patientsLevel of consensus: Strong consensus (100%)
Whenever ICP is labile and shivering is detected, neuromuscular blockers should be considered after ensuring appropriate depth of sedationLevel of consensus: Strong consensus (94%)
In self-ventilating patients in the subacute phase of severe TBI, an individualised risk–benefit assessment should be undertaken regarding the indications of controlled normothermiaLevel of consensus: Strong consensus (100%)
Permissive hyperthermia should be considered in cases where risk of secondary brain injury resulting from pyrexia is thought to be low, and when shivering cannot be controlled with first line treatments such as NSAIDs, opiates, magnesium or counter warmingLevel of consensus: Moderate consensus (83%)

Auditing

Time within target range, burden of fever and similar metrics can be considered as indicators of quality of temperature managementLevel of consensus: Strong consensus (94%)

Abstract

Aims and scope: The aim of this panel was to develop consensus recommendations on targeted temperature control (TTC) in patients with severe traumatic brain injury (TBI) and in patients with moderate TBI who deteriorate and require admission to the intensive care unit for intracranial pressure (ICP) management.

Methods: A group of 18 international neuro-intensive care experts in the acute management of TBI participated in a modified Delphi process. An online anonymised survey based on a systematic literature review was completed ahead of the meeting, before the group convened to explore the level of consensus on TTC following TBI. Outputs from the meeting were combined into a further anonymous online survey round to finalise recommendations. Thresholds of ≥ 16 out of 18 panel members in agreement (≥ 88%) for strong consensus and ≥ 14 out of 18 (≥ 78%) for moderate consensus were prospectively set for all statements.

Results: Strong consensus was reached on TTC being essential for high-quality TBI care. It was recommended that temperature should be monitored continuously, and that fever should be promptly identified and managed in patients perceived to be at risk of secondary brain injury. Controlled normothermia (36.0–37.5 °C) was strongly recommended as a therapeutic option to be considered in tier 1 and 2 of the Seattle International Severe Traumatic Brain Injury Consensus Conference ICP management protocol. Temperature control targets should be individualised based on the perceived risk of secondary brain injury and fever aetiology.

Conclusions: Based on a modified Delphi expert consensus process, this report aims to inform on best practices for TTC delivery for patients following TBI, and to highlight areas of need for further research to improve clinical guidelines in this setting.

Supplementary Information: The online version contains supplementary material available at 10.1186/s13054-024-04951-x.

Contents of the original publication

The section headings of the original.

Introduction
Methods
Review of the literature and evidence quality assessment
Participants
Delphi rounds
Definitions
Results
Discussion
Pathophysiology
Monitoring
ICP management
Fever
Hypothermic TTC induction
TTC maintenance
Rewarming following hypothermic TTC
TTC for shivering
Auditing
Summary
Strengths and limitations
Conclusion

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