• Neeraj Badjatia, Evangelia Strongilis, Mary Prescutti, Luis Fernandez, Andres Fernandez, Manuel Buitrago, J Michael Schmidt, and Stephan A Mayer.
• Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA. nbadjatia@neuro.columbia.edu
• Crit. Care Med. 2009 Jun 1;37(6):1893-7.

ObjectiveTo determine the impact of counter warming (CW) with an air circulating blanket on shivering and metabolic profile during therapeutic temperature modulation (TTM).DesignA prospective observational study.SettingAn 18-bed neurologic intensive care unit.PatientsFifty mechanically ventilated patients with brain injury undergoing TTM with automated surface and intravascular devices.InterventionsFifty indirect calorimetry (IDC) measurements with and without CW during TTM.Measurements And Main ResultsIDC was continuously performed for 10-15 minutes at baseline with CW (phase I), off CW (phase II), and again after the return of CW (phase III). Shivering severity during each phase was scored on a scale of 0-3 using the Bedside Shivering Assessment Scale (BSAS). Resting energy expenditure (REE), oxygen consumption, and carbon dioxide production were determined by IDC; 56% were women, with mean age 61 +/- 15 years. At the time of IDC, 72% of patients had signs of shivering (BSAS >0). All measures of basal metabolism increased after removal of the air warming blanket (from phases I and II); REE increased by 27% and oxygen consumption by 29% (both p < 0.002). A one-point increase in baseline BSAS was noted in 55% (n = 23/42) of patients from phase I to phase II. In a multivariate analysis, sedative use (p = 0.03), baseline moderate to severe shivering (p = 0.04), and lower serum magnesium levels (p = 0.01) were associated with greater increases in REE between phase I and phase II of CW. Phase III of CW was associated with a reversal in the increases in all metabolic variables.ConclusionsSurface CW provides beneficial control of shivering and improves the metabolic profile during TTM.

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