American Journal of Emergency Medicine 33 (2015) 124.e5-124.e7

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: locate/ ajem

Case Report

Successful management of heat stroke associated with multiple-organ dysfunction by active Intravascular cooling

Abstract

Heat stroke is a life-threatening condition requiring immediate initiation of rapid and effective cooling. We report successful cooling with initial intravascular cooling use that rapidly achieved the target temperature with continued normothermia thereafter.

A 39-year-old previously healthy man collapsed on a hot, humid day and presented with a disturbance of consciousness. On initial examination, Glasgow Coma Scale score was 6/15, and his body temperature was 40.7?C. He was therefore intubated, and fluid resuscitation was initiated. A Cool Line catheter (Asahi KASEI ZOLL Medical, Tokyo, Japan) was inserted, and aggressive cooling was started using the intravascular balloon-catheter system (The Thermogard XP system; Asahi KASEI ZOLL Medical) within 32 minutes of arrival. His core temperature reached 38.8?C after 17 minutes of intravascular cooling at an average Cooling rate of 0.10?C/min. Further investigation revealed impaired liver function and renal failure. His hemodynamic condition was stabilized, and no vasoactive agents were administrated during hospitalization. The cooling catheter was removed on day 2 of admission, and no bleeding, infection, or thrombosis associated with catheter placement was observed. Blood and urine cultures remained negative. Extubation was performed on day 3, and he was discharged on day 5 without further complication or sequelae.

It is essential in the treatment of heat stroke to cool as quickly as possible and to provide Cardiovascular support. In patients with severe heat stroke and multiple-organ dysfunction, initial use of the active intravascular cooling technique is warranted for aggressive cooling.

Heat stroke is a life-threatening injury requiring immediate initiation of rapid and effective cooling [1,2]. Several cooling methods are available including evaporation [3]; immersion [4]; cold water gastric, bladder, and rectal lavage [5]; and noninvasive cooling systems [6]. However, no evidence supports the superiority of any one cooling technique in heat stroke [1].

An intravascular balloon-catheter system has been approved in the United States for therapeutic core cooling and rewarming in humans during or after cardiac or neurologic surgery and after stroke [7]. However, there are a few case reports of the use of intravascular cooling for heat stroke [8,9], and there is no report of the initial use of an intravascular method for heat stroke management.

We report a case of severe heat stroke with secondary multiple- organ dysfunction that was successfully treated with initial intravas- cular cooling. The Thermogard XP system (Asahi KASEI ZOLL Medical, Tokyo, Japan) is approved for use by the ethics committee of Kagawa University Hospital.

A 39-year-old previously healthy man collapsed on a hot, humid summer day. He presented with disturbed consciousness and

hyperthermia, with an initial Glasgow Coma Scale score of 6/15 and a temperature of 40.7?C. His other vital signs were as follows: blood pressure, 105/75 mm Hg; heart rate, 149 beats/min; respiratory rate, 38 breaths/min; and an oxygen saturation of 100%, on 10 L/min of oxygen via a nonrebreather mask.

Because of his low Glasgow Coma Scale score, he was intubated for airway protection, and a large-bore peripheral line was sited. Cold saline was administered, and a Cool Line catheter (Asahi KASEI ZOLL Medical) was inserted into the right femoral vein to the level of the Inferior vena cava . Aggressive cooling with the intravascular balloon-catheter system (The Thermogard XP system; Asahi KASEI ZOLL Medical) was initiated 32 minutes after arrival (Fig. 1) [10]. The automated target core temperature was set at 33?C using the maximum flow rate. After 17 minutes of intravascularcooling at an average rate of 0.1?C/min, his core temperature reached 38.8?C.

Computed tomography of the head showed no cause for the disturbed consciousness, and urine Drug testing with Triage screening showed a negative result. Initial laboratory data revealed impaired liver function (glutamic-oxaloacetic transaminase and total bilirubin of 56 U/L and 1.2 mg/dL, respectively) and early acute kidney injury (serum creatinine, 1.4 mg/dL). This situation was further complicated by rhabdomyolysis and elevated creatine kinase, which peaked at 1663 U/L on the first day. The Sequential Organ Failure Assessment score was 7.

He was admitted to the intensive care unit for further Fever control and Neurocritical care (Fig. 2). The patient’s hemodynamic condition was monitored by central venous pressure measurements and by ultrasound evaluation of the IVC diameter. Central venous pressure was 12 mm Hg after the initial 2 L of fluid resuscitation, which was considered within the target range. His hemodynamic condition was therefore stabilized, and no vasoactive agents were administrated throughout his hospitalization.

The cooling catheter was removed on day 2 of admission without evidence of bleeding, infection, or thrombosis associated with the catheter placement. Blood and urine cultures remained negative throughout admission. Extubation was performed on day 3, and his subsequent hospital course was stable. He recovered well and was discharged on day 5 without neurologic sequelae.

We report a case of severe heat stroke with multiple-organ dysfunction successfully controlled with active intravascular cooling using the closed-circuit, thermostat-controlled, warm-water circulat- ing balloon catheter (the Thermogard XP system). No controlled studies have compared the effects of various cooling techniques on cooling times and outcome in patients with heat stroke [1].

Rapid and effective cooling is a primary requirement in heat stroke management, and internal cooling is more effective than external

0735-6757/(C) 2014

124.e6 H. Hamaya et al. / American Journal of Emergency Medicine 33 (2015) 124.e5–124.e7

Fig. 1. Thermogard XP and rewarming catheter system. a, The Thermogard XP system, which remotely senses changes in the patient’s core temperature, automatically adjusts this to the target set by the use of a catheter incorporating circulating saline. Reprinted courtesy of Asahi KASEI ZOLL Medical. The machine acts as a thermostat for core body temperature control, with a user-selected target temperature (31-38?C). Sterile saline from a standard 500-mL hanging bag is actively pumped through the machine and the intravascular catheter balloons, in a closed loop at 200 to 240 mL/min, depending on the catheter type. Within the machine, the saline first passes through an air trap and then passes through a metal heat exchange coil submerged in a temperature-controlled coolant well that contains a mixture of propylene glycol and distilled water. The saline then circulates through balloons on the intravascular surface of one of the specially designed central venous catheters at temperatures between 0?C and 42?C to deliver or remove heat from the bloodstream. b, The Cool Line catheter. The catheter is inserted into the common femoral vein and lodges in the IVC. Saline flow within the balloon creates a proprietary vortex flow pattern, which maximizes heat exchange with blood as it passes through. Reprinted courtesy of Asahi KASEI ZOLL Medical.

cooling [11]. Recently, 2 patients with severe stroke were treated with intravascular cooling; however, rapid cooling was not applied initially on admission [8,9]. Moreover, both cases developed high-grade fevers on several occasions after the initial cooling, which probably occurred because of inadequate initial cooling [8,9]. However, in our case, intravascular cooling was initiated early, resulting in a target temperature of less than 39?C within 1 hour of hospitalization, followed by the maintenance of normothermia.

Hart et al [12] found that in patients with heat stroke, the necessity for supplementary vasoactive agents to raise blood pressure was associated with increases in both mortality and neurologic disability.

Prevention and treatment of hemodynamic instability associated with heat stroke may contribute to improved outcomes [13]. Thus, essential points in the treatment of heat stroke are rapid cooling and cardiovascular support. The current technique facilitates rapid cooling and CVP monitoring, and functions as an administration route for vasoactive agents. In the present case, close hemodynamic monitoring of CVP and IVC diameter provided key information about the Hemodynamic state.

Recently, severe heat stroke has been successfully treated with selective therapeutic hypothermia using an automated surface cooling device (water circulating gel-coated pads) [6,14]. The advantage of

Fig. 2. Hospital course. SOFA, sequential organ failure assessment; SBP, systolic blood pressure.

H. Hamaya et al. / American Journal of Emergency Medicine 33 (2015) 124.e5–124.e7 124.e7

this technique was demonstrated for the rapid cooling and mainte- nance of target temperature in intensive care unit. However, the technique is used only for cooling and does not facilitate hemodynamic monitoring. Furthermore, intravascular cooling has demonstrated higher cooling rates than automated surface cooling [15].

The current method requires the placement of a cooling balloon catheter. However, because central venous access catheters are sited early in the resuscitation of most patients with severe stroke, this is not a major obstacle. A cooling balloon catheter is just an alternative to the central venous catheter in this context.

In the present case, no adverse effects were observed in association with catheter placement, including bleeding, infection, and thrombo- sis. Although the catheter used in this system has cooling balloons on the surface of the intravascular portion, the incidence of complications may not be different from that of central venous catheters.

In patients with severe heat stroke and multiple-organ dysfunc- tion, the early use of active intravascular cooling represents an aggressive and effective cooling technique. Further study is required to address the indications for this technique.

Hideyuki Hamaya, MD Toru Hifumi, MD? Kenya Kawakita MD Tomoya Okazaki, MD Kazutaka Kiridume, MD Natsuyo Shinohara, MD

Yuko Abe, MD Koshiro Takano, MD Masanobu Hagiike, MD Yasuhiro Kuroda, MD

emergency medical center, Kagawa University Hospital

Kagawa, 761-0793, Japan

?Corresponding author. Emergency Medical Center Kagawa University Hospital, 1750-1, Miki Kita, Kagawa, 761-0793, Japan

Tel.:+81 87 891 2392: fax:+81 87 891 2393

Email addresses: [email protected] (H. Hamaya)

[email protected] (T. Hifumi) [email protected] (K. Kawakita) [email protected] (N. Okazaki) [email protected] (Y. Kiridume)

[email protected] (N. Shinohara) [email protected] (Y. Abe) [email protected] (K. Takano) [email protected] (H. Hagiike) [email protected] (Y. Kuroda)

http://dx.doi.org/10.1016/j.ajem.2014.05.056

References

1. Bouchama A, Knochel JP. Heat stroke. N Engl J Med 2002;346:1978-88.
2. Armstrong LE, Epstein Y, Greenleaf JE, Haymes EM, Hubbard RW, Roberts WO, et al. American College of Sports Medicine position stand. Heat and cold illnesses during distance running. Med Sci Sports Exerc 1996;28:i-x.
3. Al-Aska AK, Abu-Aisha H, Yaqub B, Al-Harthi SS, Sallam A. Simplified cooling bed for heatstroke. Lancet 1987;1:381.
4. Weiner JS, Khogali M. A physiological body-cooling unit for treatment of heat stroke. Lancet 1980;1:507-9.
5. White JD, Riccobene E, Nucci R, Johnson C, Butterfield AB, Kamath R. Evaporation versus iced gastric lavage treatment of heatstroke: comparative efficacy in a Canine model. Crit Care Med 1987;15:748-50.
6. Hong JY, Lai YC, Chang CY, Chang SC, Tang GJ. Successful treatment of severe heatstroke with therapeutic hypothermia by a noninvasive external cooling system. Ann Emerg Med 2012;59:491-3.
7. Diringer MN. Treatment of fever in the neurologic intensive care unit with a catheter-based heat exchange system. Crit Care Med 2004;32:559-64.
8. Broessner G, Beer R, Franz G, Lackner P, Engelhardt K, Brenneis C, et al. Case report: severe heat stroke with Multiple organ dysfunction–a novel intravascular treatment approach. Crit Care 2005;9:R498-501.
9. Megarbane B, Resiere D, Delahaye A, Baud FJ. Endovascular hypothermia for heat stroke: a case report. Intensive Care Med 2004;30:170.
10. Kiridume KTH, Kawakita K, Okazaki T, Hamaya H, Shinohara N, Abe Y, et al. Clinical experience with an active intravascular rewarming technique for near-severe hypothermia associated with traumatic injury. J Intensive Care 2014;2.
11. Glazer JL. Management of heatstroke and heat exhaustion. Am Fam Physician 2005;71:2133-40.
12. Hart GR, Anderson RJ, Crumpler CP, Shulkin A, Reed G, Knochel JP. Epidemic classical heat stroke: clinical characteristics and course of 28 patients. Medicine 1982;61:189-97.
13. Bouchama A, Dehbi M, Chaves-Carballo E. Cooling and hemodynamic management in heatstroke: practical recommendations. Crit Care 2007;11:R54.
14. Lee EJ, Lee SW, Park JS, Kim SJ, Hong YS. Successful treatment of severe heat stroke with selective therapeutic hypothermia using an automated surface cooling device. Resuscitation 2013;84:e77-8.
15. Hoedemaekers CW, Ezzahti M, Gerritsen A, van der Hoeven JG. Comparison of cooling methods to induce and maintain normo- and hypothermia in intensive care unit patients: a prospective intervention study. Crit Care 2007;11:R91.