Neurocrit Care DOI 10.1007/s12028-014-0038-0
REVIEW ARTICLE
Monitoring Inflammation (Including Fever) in Acute Brain Injury J. Javier Provencio • Neeraj Badjatia • And the Participants in the International Multi-disciplinary Consensus Conference on Multimodality Monitoring
Springer Science+Business Media New York 2014
Abstract Inflammation is an important part of the normal physiologic response to acute brain injury (ABI). How inflammation is manifest determines if it augments or hinders the resolution of ABI. Monitoring body temperature, the cellular arm of the inflammatory cascade, and inflammatory proteins may help guide therapy. This summary will address the utility of inflammation monitoring in brain-injured adults. An electronic literature search was conducted for English language articles describing the testing, utility, and optimal methods to measure inflammation in ABI. Ninety-four articles were included in this review. Current evidence suggests that control of inflammation after ABI may hold promise for advances in good outcomes. However, our understanding of how much inflammation is good and how much is deleterious is not yet clear. Several important concepts emerge form our review. First, while continuous temperature monitoring of core body temperature is recommended, temperature pattern alone is not useful in distinguishing infectious from noninfectious fever. Second, when targeted temperature management is used, shivering should be monitored at least hourly. Finally, white blood cell levels and protein markers of inflammation may have a limited role in distinguishing infectious from noninfectious fever. Our understanding of
The Participants in the International Multi-disciplinary Consensus Conference on Multimodality Monitoring are listed in ‘‘Appendix’’. J. J. Provencio (&) Cleveland Clinic Lerner College of Medicine, NC30, 9500 Euclid Ave., Cleveland, OH 44195, USA e-mail: [email protected] N. Badjatia University of Maryland School of Medicine, Baltimore, MD, USA
optimal use of inflammation monitoring after ABI is limited currently but is an area of active investigation. Keywords Monitoring Inflammation Fever Brain injury Neurocritical care Shivering C-reactive protein Abbreviations SAH Subarachnoid hemorrhage DCI Delayed cerebral injury associated with vasospasm IL-6 Intraleukin 6 CRP C-reactive protein TTM Therapeutic temperature modulation WBC White blood cell count TNFa Tumor necrosis factor SIRS Systemic inflammatory response syndrome BSAS Bedside Shivering Assessment Scale IDC Indirect calorimetry
Introduction Inflammation as a concept dates back to 25 AD when Celsus described rubor, dolor, calor, and tumor as the cardinal signs of inflammation [1]. Medical understanding has evolved from this simple, elegant definition to our understanding of a complicated system of host defense rivaled only by the central nervous system. The inflammatory system has not evolved to service the types of diseases we currently see in the modern intensive care unit. There has been a little evolutionary pressure to mitigate the effects of overwhelming inflammation in, for example, intracerebral hemorrhage (ICH), as this type of disease was likely uniformly fatal in pre-civilized human existence. Instead, we have a system of
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defense that is still essential for protection against pathogens and insults of a milder variety but is ill suited for the magnitude of injury we currently treat in neurocritical care. Current evidence suggests that controlling inflammation early after brain diseases may hold the most promise for advances in good outcomes, but our experience with glucocorticosteroids (potent anti-inflammatory agents) in ICH shows that our understanding of how much inflammation is good and how much deleterious is not yet clear [2]. The main areas where monitoring inflammation holds hope of benefit are the monitoring of fever, the monitoring of cellular aspects of the immune system, and the monitoring of molecules that are the markers of inflammation in fluids obtained from patients. Biomarkers used to detect brain injury, although often tightly linked to inflammation are covered elsewhere in this supplement.
Methods An extensive librarian-and investigator-led search was conducted using key words specific to infection, temperature, and inflammation according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [3]. A systematic review of English language studies published between 1966 and August 2013 was performed using the PubMed database. The focus was on adult patients with brain disorders.
excluded: (a) review articles; (b) case reports or case series with B5 patients; (c) experimental studies; (d) study on pediatric ICU populations (
REVIEW ARTICLE
Monitoring Inflammation (Including Fever) in Acute Brain Injury J. Javier Provencio • Neeraj Badjatia • And the Participants in the International Multi-disciplinary Consensus Conference on Multimodality Monitoring
Springer Science+Business Media New York 2014
Abstract Inflammation is an important part of the normal physiologic response to acute brain injury (ABI). How inflammation is manifest determines if it augments or hinders the resolution of ABI. Monitoring body temperature, the cellular arm of the inflammatory cascade, and inflammatory proteins may help guide therapy. This summary will address the utility of inflammation monitoring in brain-injured adults. An electronic literature search was conducted for English language articles describing the testing, utility, and optimal methods to measure inflammation in ABI. Ninety-four articles were included in this review. Current evidence suggests that control of inflammation after ABI may hold promise for advances in good outcomes. However, our understanding of how much inflammation is good and how much is deleterious is not yet clear. Several important concepts emerge form our review. First, while continuous temperature monitoring of core body temperature is recommended, temperature pattern alone is not useful in distinguishing infectious from noninfectious fever. Second, when targeted temperature management is used, shivering should be monitored at least hourly. Finally, white blood cell levels and protein markers of inflammation may have a limited role in distinguishing infectious from noninfectious fever. Our understanding of
The Participants in the International Multi-disciplinary Consensus Conference on Multimodality Monitoring are listed in ‘‘Appendix’’. J. J. Provencio (&) Cleveland Clinic Lerner College of Medicine, NC30, 9500 Euclid Ave., Cleveland, OH 44195, USA e-mail: [email protected] N. Badjatia University of Maryland School of Medicine, Baltimore, MD, USA
optimal use of inflammation monitoring after ABI is limited currently but is an area of active investigation. Keywords Monitoring Inflammation Fever Brain injury Neurocritical care Shivering C-reactive protein Abbreviations SAH Subarachnoid hemorrhage DCI Delayed cerebral injury associated with vasospasm IL-6 Intraleukin 6 CRP C-reactive protein TTM Therapeutic temperature modulation WBC White blood cell count TNFa Tumor necrosis factor SIRS Systemic inflammatory response syndrome BSAS Bedside Shivering Assessment Scale IDC Indirect calorimetry
Introduction Inflammation as a concept dates back to 25 AD when Celsus described rubor, dolor, calor, and tumor as the cardinal signs of inflammation [1]. Medical understanding has evolved from this simple, elegant definition to our understanding of a complicated system of host defense rivaled only by the central nervous system. The inflammatory system has not evolved to service the types of diseases we currently see in the modern intensive care unit. There has been a little evolutionary pressure to mitigate the effects of overwhelming inflammation in, for example, intracerebral hemorrhage (ICH), as this type of disease was likely uniformly fatal in pre-civilized human existence. Instead, we have a system of
123
Neurocrit Care
defense that is still essential for protection against pathogens and insults of a milder variety but is ill suited for the magnitude of injury we currently treat in neurocritical care. Current evidence suggests that controlling inflammation early after brain diseases may hold the most promise for advances in good outcomes, but our experience with glucocorticosteroids (potent anti-inflammatory agents) in ICH shows that our understanding of how much inflammation is good and how much deleterious is not yet clear [2]. The main areas where monitoring inflammation holds hope of benefit are the monitoring of fever, the monitoring of cellular aspects of the immune system, and the monitoring of molecules that are the markers of inflammation in fluids obtained from patients. Biomarkers used to detect brain injury, although often tightly linked to inflammation are covered elsewhere in this supplement.
Methods An extensive librarian-and investigator-led search was conducted using key words specific to infection, temperature, and inflammation according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [3]. A systematic review of English language studies published between 1966 and August 2013 was performed using the PubMed database. The focus was on adult patients with brain disorders.
excluded: (a) review articles; (b) case reports or case series with B5 patients; (c) experimental studies; (d) study on pediatric ICU populations (
