Cooling

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There are physical methods for reducing fever but in some areas of practice such as general ITU there is little good evidence that they work and if applied excessively can make things worse[1]. It is possible that inducing shivering by such methods is a marker of such excess[2].

On the other hand a standard proven treatment in exertional heat stroke is immediate total immersion in an ice bath[3][4] and is better than a water cooled vest[5].

For milder degrees of fever associated with minor infection, persuading people to remove clothes (and persuading parents to remove a child's clothing) is sometimes quite difficult, but this along with turning down the heating and letting in cool air may be effective in limiting fever, and other methods without this are unlikely to be effective.

Tepid sponging for children is no longer recommended [6] but remains popular. Avoiding over dressing seems sensible.

Therapeutic hypothermia has been used for hypoxic ischaemic encephalopathy in neonates. Can be done by head cooling or whole body cooling, to about 33.5 degC. Cochrane review finds in favour: reduced mortality/major neurodevelopmental disability at 18 months of age (typical RR 0.76) which gives NNT of 8-11. [7] A variety of complications are described but their incidence seems very low. But many studies are still ongoing (given the long follow up). [8]

Cooling is also important in the management of adrenergic, serotonic and anticholinergic drug toxicity including MDMA (Ecstasy).[9]. Techniques include packing ice around the areas of large arteries, and washing the peritoneum or stomach with cold fluid. Cardiopulmonary bypass allows direct control of the temperature.

Malignant hyperthermia and neuroleptic malignant syndrome have specific treatments distinct from cooling.

References

  1. Schulman CI, Namias N, Doherty J, Manning RJ, Li P, Alhaddad A, Lasko D, Amortegui J, Dy CJ, Dlugasch L, Baracco G, Cohn SM. The effect of antipyretic therapy upon outcomes in critically ill patients: a randomized, prospective study. Surgical infections. 2005; 6(4):369-75.(Link to article – subscription may be required.)
  2. Badjatia N, Kowalski RG, Schmidt JM, Voorhees ME, Claassen J, Ostapkovich ND, Presciutti M, Connolly ES, Palestrant D, Parra A, Mayer SA. Predictors and clinical implications of shivering during therapeutic normothermia. Neurocritical care. 2007; 6(3):186-91.(Link to article – subscription may be required.)
  3. Roberts WO. Exertional heat stroke in the marathon. Sports medicine (Auckland, N.Z.). 2007; 37(4-5):440-3.
  4. Glazer JL. Management of heatstroke and heat exhaustion. American family physician. 2005 Jun 1; 71(11):2133-40.
  5. Lopez RM, Cleary MA, Jones LC, Zuri RE. Thermoregulatory influence of a cooling vest on hyperthermic athletes. Journal of athletic training. 2008 Jan-Mar; 43(1):55-61.
  6. Nice Guideline CG47
  7. Jacobs S, Hunt R, Tarnow-Mordi W, Inder T, Davis P. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane database of systematic reviews (Online). 2007; (4):CD003311.(Epub) (Link to article – subscription may be required.)
  8. Shankaran S, Pappas A, Laptook AR, McDonald SA, Ehrenkranz RA, Tyson JE, Walsh M, Goldberg RN, Higgins RD, Das A. Outcomes of safety and effectiveness in a multicenter randomized, controlled trial of whole-body hypothermia for neonatal hypoxic-ischemic encephalopathy. Pediatrics. 2008 Oct; 122(4):e791-8.(Link to article – subscription may be required.)<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=18447921 Azzopardi D, Brocklehurst P, Edwards D, Halliday H, Levene M, Thoresen M, Whitelaw A. The TOBY Study. Whole body hypothermia for the treatment of perinatal asphyxial encephalopathy: a randomised controlled trial. BMC pediatrics. 2008; 8:17.]<small>(Epub) </small><small>([http://dx.doi.org/10.1186/1471-2431-8-17 Link to article] &ndash; subscription may be required.)</small></li> <li id="cite_note-8">[[#cite_ref-8|↑]] [http://www.ncbi.nlm.nih.gov/sites/entrez?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=18096088 Eyer F, Zilker T. Bench-to-bedside review: mechanisms and management of hyperthermia due to toxicity. Critical care (London, England). 2007; 11(6):236.]<small>([http://dx.doi.org/10.1186/cc6177 Link to article] &ndash; subscription may be required.)</small></li></ol></ref>
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