A touch of cooling may help

Akram M Zaaqoq, Sachin Yende

EXPANDED ABSTRACT: CITATION: Schortgen F, Clabault K, Katsahian S, Devaquet J, Mercat A, Deye N, Dellamonica J, Bouadma L, Cook F, Beji O, Brun-Buisson C, Lemaire F, Brochard L: Multicenter randomized controlled clinical trial of fever control by external cooling to diminish vasopressor requirements in septic shock. Assistance Publique-Hôpitaux de Paris, France. Am J Respir Crit Care Med 2012, 185:1088-1095. BACKGROUND: Fever control may improve vascular tone and decrease oxygen consumption; however, fever may help combat infection. METHODS: OBJECTIVE: To determine whether fever control by external cooling diminishes vasopressor requirements in septic shock. DESIGN: A multicenter randomized controlled trial. SETTING: Seven ICUs in France. SUBJECTS: Febrile patients with septic shock requiring vasopressors, mechanical ventilation, and sedation. INTERVENTION: Patients were randomly allocated to external cooling to achieve normothermia (36.5 to 37.8°C) for 48 hours. OUTCOMES: The primary outcome was the number of patients with a 50% decrease in baseline vasopressor dose after 48 hours. Secondary outcomes were the numbers of patients with a 50% baseline vasopressor dose decrease after 2, 12, 24, and 36 hours, the percentage of patients requiring a vasopressor dose increase within 48 hours of baseline, the percentage of patients with shock reversal in the ICU, the change in Sequential Organ Failure Assessment score (ΔSOFA) versus baseline, and all-cause mortality on day 14 and at ICU and hospital discharge. RESULTS: There were 200 patients randomized, 101 to the cooling group and 99 to the no-cooling group. The percentage of patients with a 50% vasopressor dose decrease versus baseline was not significantly different at 48 hours of treatment (72% vs. 61%; absolute difference, 11%; 95% confidence interval (CI), -23 to 2; P = 0.4), although it was at 12 hours (54% vs. 20%; absolute difference, 34%; 95% CI, -46 to -21; P < 0.001). External cooling significantly reduced the number of patients needing a vasopressor dose increase (34% vs. 52%; absolute difference, -18%; 95% CI, -4 to -31%; P = 0.011) and significantly increased the shock reversal during the study period (86% vs. 73%; absolute difference, 13%; 95% CI, 2 to 25%; P = 0.021). Day 14 mortality was significantly lower in the cooling group (19% vs. 34%; absolute difference, -16%; 95% CI, -28 to -4; P = 0.013), but mortality was not different at ICU and hospital discharge. CONCLUSIONS: Fever control using external cooling was safe, and decreased vasopressor requirements and early mortality in septic shock.