Therapeutic hypothermia for head injury
Abstract
Background
Induced hypothermia has been used in the treatment of head injury for many years. Encouraging results from small trials and laboratory studies led to renewed interest in the area and some larger trials.
Objectives
To estimate the effects of mild induced hypothermia in moderate and severe head injury on mortality, long‐term functional outcome, complications, and short‐term control of intracranial pressure (ICP).
Search methods
We searched the Injuries Group Specialised register, CENTRAL, MEDLINE and EMBASE. We handsearched conference proceedings and checked reference lists of relevant articles, including a systematic review published in 2003.
Selection criteria
Randomised controlled trials of mild hypothermia to 34 to 35ºC for at least 12 hours versus control (open or normothermia) in patients with any closed head injury requiring hospitalisation. Two authors independently assessed all trials.
Data collection and analysis
Data on death, Glasgow outcome scale, complications and ICP were sought and extracted, either from published material or by contacting the investigators. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each trial on an intention‐to‐treat basis. Quantitative synthesis of data on complications other than pneumonia or ICP was not attempted. Trials of immediate and deferred hypothermia were analysed separately.
Main results
We found 14 trials with 1094 participants. Active immediate hypothermia was associated with an OR for death of 0.80, (1061 patients, OR 0.80, 95% CI 0.61 to 1.04), and 0.75 for odds of being dead or severely disabled, (746 patients, OR 0.75, 95% CI 0.56 to 1.00). Hypothermia treatment was associated with a statistically significant increase in odds of pneumonia (281 patients, OR 1.95, 95% CI 1.18 to 3.23).
The trial of deferred hypothermia (33 patients) reported a huge but not statistically significant reduction in the odds of death at six months, (OR 0.21, 95% CI 0.04 to 1.05). For death or severe disability, deferred hypothermia was associated with an OR of 0.10 (95% CI 0.01 to 1.00).
Authors' conclusions
There is no evidence that hypothermia is beneficial in the treatment of head injury. The earlier, encouraging, trial results have not been repeated in larger trials. The reasons for this are unclear. Hypothermia increases the risk of pneumonia and has other potentially harmful side‐effects. Therefore, it would seem inappropriate to use this intervention outside of controlled trials in subgroups of patients for whom there is good reason to think the treatment would be beneficial.
PICOs
Plain language summary
Hypothermia therapy after traumatic brain injury has not been shown to reduce death or disability, and it increases the risk of pneumonia
Severe head injury can damage the brain, and damage continues occurring in the brain for some time after the initial injury. Mild hypothermia treatment (cooling) has been a common strategy to slow down some of the brain changes that cause continuing damage. However, while hypothermia might slow down some harmful actions in the brain, potential major adverse effects include pneumonia (chest infection), blood flow problems or heart complications. The review of trials found that hypothermia therapy has not been shown to reduce death or disability after traumatic brain injury. However, hypothermia increases the risk of pneumonia and other life‐threatening complications.
