Practicability of therapeutic hypothermia after traumatic brain injury

There is a lack of proof of general efficacy of systemic cooling therapy in the treatment of acute severe traumatic brain injury (TBI) with regard to improving outcomes. To appraise the understanding and evidence concerning therapeutic hypothermia for TBI, clinical trials, meta-analyses, and knowledge of the last 20 years as well as expert opinions have been evaluated. Relating evidence to practicability, it has been shown that patients with isolated TBI or TBI combined with no serious other injuries will only experience improved outcomes if prophylactic hypothermia lasted at least 48 - 72 hours and/or ICP normalized for at least 24 hours at a targeted body core temperature of 33 - 35 °C, roughly equivalent to a brain temperature of 35 °C; in addition, rewarming had to be performed with a maximum rate of 1 °C per 4 - 8 hours and in case of an increase in ICP had to be cancelled or cooling had to be restarted. This, however, could only be observed if good intensive care adapted to individual patients' needs was available even after cooling therapy had been stopped. Therapeutic hypothermia used for reduction of intracranial hypertension always decreased a raised ICP at a core temperature of 32 - 34 °C as compared to normothermia. In case of a multimodal approach, the reduction in ICP was more effective than with hyperventilation, mannitol, or barbiturates. In conclusion, therapeutic hypothermia after TBI is practicable; a long-term benefit, however, has so far only been shown in specific patient groups and with optimized treatment strategies.