Characterizing the impact of thermoregulation in patients after cardiac arrest: a retrospective cohort study.

PURPOSE: Core body temperature has been extensively investigated as a thereuptic target in care after cardiac arrest. Nevertheless, the integrity of thermoregulation in patients after cardiac arrest has not been well studied. We sought to evaluate whether low spontaneous body temperature after cardiac arrest is associated with increased death and a worse neurologic outcome, and whether patients with low spontaneous body temperature exhibit features suggestive of impaired thermoregulation. METHODS: We conducted a single-centre retrospective cohort study. We included all adult patients who underwent temperature control with hypothermia after cardiac arrest between 1 January 2014 and 30 June 2020. The primary exposure was low spontaneous core body temperature (< 35 °C) at initiation of hypothermia therapy. The primary outcome was in-hospital death and the secondary outcome was poor neurologic outcomes at discharge. RESULTS: Five hundred and ninety-seven adult patients, comprising both in- and out-of-hospital cardiac arrests, were included. Patients with low spontaneous body temperature also had slightly lower average temperature, and more frequent transient but controlled breakthrough fever episodes in the first 24 hr. In the multivariable logistic regression analysis, low spontaneous body temperature was associated with higher odds of in-hospital death (odds ratio, 2.9; 95% confidence interval, 1.9 to 4.2; P < 0.001). CONCLUSION: In this single-centre retrospective cohort study, low spontaneous core body temperature was associated with poor outcomes in patients after cardiac arrest. Patients with low spontaneous body temperature also exhibited features suggestive of impaired thermoregulation. Further research is needed to determine whether body temperature upon presentation reflects the robustness of the patient's underlying physiology and severity of brain insult after a cardiac arrest.

RéSUMé: OBJECTIF: La température corporelle centrale a fait l'objet d'études approfondies en tant que cible thérapeutique dans les soins après un arrêt cardiaque. Néanmoins, l'intégrité de la thermorégulation après un arrêt cardiaque n'a pas été bien étudiée. Nous avons cherché à évaluer si une température corporelle spontanément basse après un arrêt cardiaque était associée à une augmentation de la mortalité et à une issue neurologique plus grave, et si les individus ayant une température corporelle spontanément basse présentaient des caractéristiques suggérant une altération de la thermorégulation. MéTHODE: Nous avons mené une étude de cohorte rétrospective monocentrique. Nous avons inclus tou·tes les patient·es adultes ayant bénéficié d'un contrôle de température lors d'une hypothermie après un arrêt cardiaque entre le 1er janvier 2014 et le 30 juin 2020. L'exposition principale était une température corporelle centrale spontanément basse (< 35 °C) au début du traitement de l'hypothermie. Le critère d'évaluation principal était le décès à l'hôpital, et le critère d'évaluation secondaire était de mauvaises issues neurologiques à la sortie de l'hôpital. RéSULTATS: Cinq cent quatre-vingt-dix-sept patient·es adultes, ayant subi des arrêts cardiaques à l'hôpital ou hors de l'hôpital, ont été inclus·es. Les patient·es ayant une température corporelle spontanément basse avaient également une température moyenne légèrement plus basse et des épisodes de fièvre paroxystique transitoires mais contrôlés plus fréquents au cours des premières 24 heures. Dans l'analyse de régression logistique multivariée, une température corporelle spontanément basse était associée à une probabilité plus élevée de décès à l'hôpital (rapport de cotes, 2,9; intervalle de confiance à 95 %, 1,9 à 4,2; P < 0,001). CONCLUSION: Dans cette étude de cohorte rétrospective monocentrique, une température corporelle centrale spontanément basse a été associée à de mauvais devenirs après un arrêt cardiaque. Les patient·es présentant une température corporelle spontanément basse présentaient également des caractéristiques suggérant une altération de la thermorégulation. D'autres recherches sont nécessaires pour déterminer si la température corporelle lors de la présentation reflète la robustesse de la physiologie sous-jacente des patient·es et la gravité de la lésion cérébrale après un arrêt cardiaque.

Postarrest Care Bundle Improves Quality of Care and Clinical Outcomes in the Normothermia Era.

PURPOSE: Temperature targets in patients with cardiac arrest and return of spontaneous circulation (ROSC) have changed. Changes to higher temperature targets have been associated with higher breakthrough fevers and mortality. A post-ROSC normothermia bundle was developed to improve compliance with temperature targets. METHODS: In August 2021, "ad hoc" normothermia at the discretion of the attending intensivist was initiated. In December 2021, a post-ROSC normothermia protocol was implemented, incorporating a rigorous, stepwise approach to fever prevention (temperature ≥ 37.8). We conducted a before-after cohort study of all adult patients post-ROSC who survived to intensive care unit admission between August 1, 2021, and April 1, 2022. They were divided into "ad hoc" and "protocol" groups. Clinical outcomes compared included fevers, active cooling, and paralytic use. RESULTS: Fifty-eight post-ROSC patients were admitted; 24 in the "ad hoc" and 34 in the "protocol" groups. Patient demographics were similar between groups. The "ad hoc" group had more shockable rhythms (67% vs 24%, P = .001) and cardiac catheterizations (42% vs 15%, P = .03). The "protocol" group were significantly less likely to have a fever at 40 h (6% vs 40%, P < .001) and 72 h (14% vs 65%, P ≤ .001). Patients in the normothermia "protocol" used significantly less neuromuscular blocking agents (24% vs 50%, P = .05). The normothermia "protocol" resulted in similar mortality (56% vs 58%, P = 1.0). CONCLUSION: Use of a normothermia "protocol" resulted in fewer fevers and less neuromuscular blocker administration compared to "ad hoc" management. A protocolized approach for improved quality of care should be considered in institutions adopting normothermia.

Point-of-care lung and cardiac ultrasound (LUCAS) study in hip fracture patients: a prospective cohort study.

PURPOSE: A clinical conflict often presented with hip fracture patients is whether to proceed with timely surgery or delay surgery until a formal echocardiogram is conducted. This study aimed to assess the impact of incorporating point-of-care lung and cardiac ultrasound (LUCAS) scans as part of the preoperative assessment for hip fracture patients. METHODS: We recruited 225 consecutive adult patients booked for urgent hip arthroplasty surgery. A LUCAS scan was performed for each patient. The anesthesiologists were asked to provide their anesthetic plans before and after acknowledging the results of the LUCAS scans. The primary endpoint was a composite outcome of changes to the anesthetic plan. The secondary outcomes included anesthesiologists' opinions of the LUCAS scans. RESULTS: One-hundred-ninety-eight patients were included. The majority of LUCAS findings were not severe. A common abnormal finding was hypovolemia (31%). One-hundred-and-six anesthetic management decisions were changed, with 59 of these changes being an escalation of the anesthetic plan, and 47 of these changes being a de-escalation. Eighty-three percent of anesthesiologists agreed that LUCAS affirmed their anesthetic plans and should be an integral part of the perioperative assessment. CONCLUSION: This study found that LUCAS scans did not significantly alter the anesthetic plan for hip fracture patients. Nevertheless, LUCAS scans can rule out severe cardiopulmonary conditions and allow for both escalation and de-escalation of care. In the setting of early hip surgery, LUCAS presents a viable option in selected patients to address the unmet need to allow for both timely surgery and comprehensive patient evaluation. STUDY REGISTRATION: ClinicalTrials.gov (NCT03275129); registered 8 July 2018.

RéSUMé: OBJECTIF: Une interrogation clinique qui existe souvent avec les patient·es se présentant avec une fracture de hanche est de savoir s'il faut procéder à une intervention chirurgicale rapidement ou retarder la chirurgie jusqu'à ce qu'un échocardiogramme formel soit réalisé. Cette étude visait à évaluer l'impact de l'intégration de l'échographie ciblée pulmonaire et cardiaque (LUCAS, Lung and Cardiac ultrasound) dans le cadre de l'évaluation préopératoire des personnes ayant subi une fracture de la hanche. MéTHODE: Nous avons recruté 225 patient·es adultes consécutif·ves devant bénéficier d'une arthroplastie urgente de la hanche. Une échographie de type LUCAS a été réalisée pour chaque patient·e. On a demandé aux anesthésiologistes de fournir leurs plans anesthésiques avant et après avoir pris connaissance des résultats des échographies de type LUCAS. Le critère d'évaluation principal était un résultat composite des modifications apportées au plan anesthésique. Les critères d'évaluation secondaires comprenaient les opinions des anesthésiologistes sur les échographies de type LUCAS. RéSULTATS: Cent quatre-vingt-dix-huit patient·es ont été inclus·es. La majorité des résultats de l'échographie de type LUCAS n'étaient pas graves. Un résultat anormal courant était l'hypovolémie (31 %). Cent six décisions de prise en charge anesthésique ont été modifiées, 59 de ces changements étant une escalade du plan anesthésique et 47 de ces changements étant une réduction. Quatre-vingt-trois pour cent des anesthésiologistes ont convenu que l'échographie de type LUCAS confirmait leurs plans anesthésiques et devrait faire partie intégrante de l'évaluation périopératoire. CONCLUSION: Cette étude a révélé que les échographies de type LUCAS ne modifiaient pas de manière significative le plan anesthésique pour les patient·es se présentant avec une fracture de hanche. Néanmoins, les échographies de type LUCAS peuvent exclure des affections cardiopulmonaires graves et permettre à la fois d'augmenter ou de réduire les soins périopératoires. Dans le cadre d'une chirurgie précoce de la hanche, l'échographie de type LUCAS présente une option viable chez une patientèle sélectionnée pour répondre à un besoin non satisfait afin de permettre à la fois une chirurgie rapide et une évaluation complète des patient·es. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03275129); enregistrée le 8 juillet 2018.

Non-Invasive Monitoring of Core Body Temperature for Targeted Temperature Management in Post-Cardiac Arrest Care.

Importance: Accurate monitoring of core body temperature is integral to targeted temperature management (TTM) following cardiac arrest. However, there are no reliable non-invasive methods for monitoring temperature during TTM. Objectives: We compared the accuracy and precision of a novel non-invasive Zero-Heat-Flux Thermometer (SpotOn™) to a standard invasive esophageal probe in a cohort of patients undergoing TTM post-cardiac arrest. Design Setting and Participants: We prospectively enrolled 20 patients undergoing post-cardiac arrest care in the intensive care units at the London Health Sciences Centre in London, Canada. A SpotOn™ probe was applied on each patient's forehead, while an esophageal temperature probe was inserted, and both temperature readings were recorded at 1-min intervals for the duration of TTM. Main outcomes and Measures: We compared the SpotOn™ and esophageal monitors using the Bland-Altman analysis and the Pearson correlation, with accuracy set as a primary outcome. Secondary outcomes included precision and correlation. Bias exceeding 0.1°C and limits of agreement exceeding 0.5°C were considered clinically important. Results: Sixteen (80%) of patients had complete data used in the final analysis. The median (interquartile range) duration of recording was 38 (12-56) h. Compared to the esophageal probe, SpotOn™ had a bias of 0.06 ± 0.45°C and 95% limits of agreement of -0.83 to 0.95°C. The Pearson correlation coefficient was 0.97 (95% confidence interval 0.9663-0.9678), with a two-tailed p < 0.0001. Conclusion and Relevance: The SpotOn™ is an accurate method that may enable non-invasive monitoring of core body temperature during TTM, although its precision is slightly worse than the predefined 0.5°C when compared to invasive esophageal probe.

Inferior vena cava assessment in term pregnant women using ultrasound: A comparison of the subcostal and right upper quadrant views.

Point-of-care ultrasound can be used at the bedside to assess the haemodynamic status and fluid responsiveness of a pregnant woman. Previous studies demonstrated that views from the apical and parasternal windows are readily obtainable in labouring women. However, using the subcostal window to assess the inferior vena cava can be challenging because of the gravid uterus. A potential alternative is the right upper quadrant transhepatic window. We sought to compare visualisation of the inferior vena cava via the subcostal and right upper quadrant windows, in full-term pregnant women. This was a prospective pilot study carried out in a tertiary academic obstetric centre. Thirty pregnant non-labouring women at full term were recruited. In each patient, the inferior vena cava was visualised through both the subcostal and the right upper quadrant windows. Time to acquire each image, acquisition success rates and ease of obtaining images were compared for both approaches. Image quality was then reviewed and rated by two independent expert reviewers. There was a significant difference in the time required to obtain each view; subcostal median (interquartile range): 52 (35-59) seconds, right upper quadrant median (interquartile range): 23 (11-55) seconds (P=0.0045). Operator-defined successful image acquisition was 100% for the right upper quadrant window compared to 80% for the subcostal window. Ease of obtaining the view, as rated by the operator, was significantly easier in the right upper quadrant window compared to the subcostal window (P <0.0001). Both reviewers independently rated image adequacy to be significantly greater in the right upper quadrant window (73% and 57%) compared to the subcostal window (40% and 10%) (P=0.0213 and P=0.0005, respectively). Inter-rater agreement ranged between good (Cohen's kappa coefficient 0.64) for right upper quadrant windows to fair (Cohen's kappa coefficient 0.29) for subcostal windows. Inferior vena cava visualisation in term pregnant patients may take less time, be easier and provide better quality images when the right upper quadrant window is used compared to the subcostal window.

Canadian recommendations for training and performance in basic perioperative point-of-care ultrasound: recommendations from a consensus of Canadian anesthesiology academic centres.

Point-of-care ultrasound (POCUS) uses ultrasound at the bedside to aid decision-making in acute clinical scenarios. The increased use of ultrasound for regional anesthesia and vascular cannulation, together with more anesthesiologists trained in transesophageal echocardiography have contributed to the widespread use of POCUS in perioperative care. Despite the support of international experts, the practice of POCUS in perioperative care is variable as Canadian guidelines for anesthesiologists do not currently exist. Using a Delphi process of online surveys and a face-to-face national Canadian meeting, we developed a consensus statement for basic POCUS (bPOCUS) performance and training with a group of national experts from all Canadian universities. The group of experts consisted of 55 anesthesiologists from 12 Canadian universities considered local leaders in the field. An initial exploratory online survey of 47 statements was conducted. These statements were derived from previous generic guidelines or consensus conferences, or were based on current literature. Fourteen statements reached full consensus, 19 had 90-100% agreement, and 14 had less than 90% agreement. Eight new statements were proposed during the national meeting, and all statements without full agreement were discussed. A second online survey included 42 modified or new statements. From this second survey, 16 statements obtained full consensus, 39 had very good agreement, and one had good agreement. The final document includes 56 statements that define the scope of practice and necessary training for perioperative bPOCUS. The statements include five bPOCUS domains: cardiac, lung, airway, gastric, and abdomen. The use of bPOCUS is evolving and will play a significant role in perioperative medicine. This consensus statement aims to define a Canadian national standard on which curricula may be based. It also provides a framework to allow further development of bPOCUS in the perioperative setting.

RéSUMé: L'échographie ciblée (POCUS) utilise l'échographie au chevet des patients pour faciliter la prise de décisions dans les situations cliniques urgentes. L'utilisation accrue de l'échographie pour l'anesthésie régionale et la cannulation vasculaire, ainsi que l'augmentation du nombre d'anesthésologistes formés à l'échocardiographie transesophagienne, ont contribué à l'utilisation généralisée de l'échographie ciblée dans les soins périopératoires. Malgré son endossement par des experts internationaux, la pratique de l'échographie ciblée en soins périopératoires est variable, car il n'existe pas, à l'heure actuelle, de lignes directrices canadiennes destinées aux anesthésiologistes. À l'aide d'un processus Delphi de sondages en ligne et d'une réunion nationale canadienne en personne, un groupe d'experts nationaux provenant de toutes les universités canadiennes a élaboré une déclaration consensuelle pour la formation de base en et l'exécution de l'échographie ciblée (bPOCUS). Le groupe d'experts était composé de 55 anesthésiologistes issus de 12 universités canadiennes considérés comme des chefs de file locaux dans le domaine. Un premier sondage exploratoire en ligne comportant 47 énoncés a été réalisé. Ces énoncés étaient dérivés de lignes directrices antérieures ou de conférences consensuelles, ou étaient fondés sur la littérature actuelle. Quatorze énoncés ont obtenu un consensus complet, 19 ont atteint un taux de 90 à 100 %, et 14 ont obtenu moins de 90 % d'accord. Huit nouveaux énoncés ont été proposés au cours de la réunion nationale, et tous les énoncés n'ayant pas obtenu d'accord complet ont été discutés. Un deuxième sondage en ligne comprenait 42 énoncés modifiés ou nouveaux. Dans ce deuxième sondage, 16 énoncés ont obtenu un consensus total, 39 un très bon accord et un énoncé un bon accord. Le document final comporte 56 énoncés qui définissent le champ de pratique et la formation nécessaire pour l'échographie ciblée périopératoire de base. Les énoncés portent sur cinq domaines de l'échographie ciblée de base : échographie cardiaque, pulmonaire, des voies respiratoires, gastrique et abdominale. L'utilisation de l'échographie ciblée de base évolue et jouera un rôle important en médecine périopératoire. Cette déclaration consensuelle vise à définir une norme nationale canadienne sur laquelle les programmes d'études pourront s'appuyer. Elle fournit également un cadre pour encourager le développement ultérieur de l'échographie ciblée de base dans un contexte périopératoire.

The Use of Central Venous to Arterial Carbon Dioxide Tension Gap for Outcome Prediction in Critically Ill Patients: A Systematic Review and Meta-Analysis.

OBJECTIVES: In this systematic review and meta-analysis, we assessed whether a high CO2 gap predicts mortality in adult critically ill patients with circulatory shock. DATA SOURCES: A systematic search of MEDLINE and EMBASE electronic databases from inception to October 2019. STUDY SELECTION: Studies from adult (age ≥ 18 yr) ICU patients with shock reporting CO2 gap and outcomes of interest. Case reports and conference abstracts were excluded. DATA EXTRACTION: Data extraction and study quality assessment were performed independently in duplicate. DATA SYNTHESIS: We used the Newcastle-Ottawa Scale to assess methodological study quality. Effect sizes were pooled using a random-effects model. The primary outcome was mortality (28 d and hospital). Secondary outcomes were ICU length of stay, hospital length of stay, duration of mechanical ventilation, use of renal replacement therapy, use of vasopressors and inotropes, and association with cardiac index, lactate, and central venous oxygen saturation. CONCLUSIONS: We included 21 studies (n = 2,155 patients) from medical (n = 925), cardiovascular (n = 685), surgical (n = 483), and mixed (n = 62) ICUs. A high CO2 gap was associated with increased mortality (odds ratio, 2.22; 95% CI, 1.30-3.82; p = 0.004) in patients with shock, but only those from medical and surgical ICUs. A high CO2 gap was associated with higher lactate levels (mean difference 0.44 mmol/L; 95% CI, 0.20-0.68 mmol/L; p = 0.0004), lower cardiac index (mean difference, -0.76 L/min/m; 95% CI, -1.04 to -0.49 L/min/m; p = 0.00001), and central venous oxygen saturation (mean difference, -5.07; 95% CI, -7.78 to -2.37; p = 0.0002). A high CO2 gap was not associated with longer ICU or hospital length of stays, requirement for renal replacement therapy, longer duration of mechanical ventilation, or higher vasopressors and inotropes use. Future studies should evaluate whether resuscitation aimed at closing the CO2 gap improves mortality in shock.

Critical Care Management of the Acute Postimplant LVAD Patient.

Left ventricular assist devices (LVADs) improve survival and quality of life in refractory end-stage heart failure. However, the therapy itself is associated with some degree of morbidity and mortality at highest risk during the first 30 days postimplantation. Management of the patient with a freshly implanted LVAD requires an in-depth understanding of the acute postimplant period and common critical care issues including coagulopathy, hemodynamic lability, and metabolic derangements. This requires meticulous hemostatic control and a firm understanding of hemodynamic principles that focus on optimizing end-organ perfusion, right-ventricular function, and measured LVAD titration. This contemporary practical guide to management of the acute postimplant LVAD patient includes a focused approach to troubleshooting common LVAD issues that may arise from the operating room to discharge from critical care.

Cardiac Intensive Care Unit Management of Patients After Cardiac Arrest: Now the Real Work Begins.

Survival with a good quality of life after cardiac arrest continues to be abysmal. Coordinated resuscitative care does not end with the effective return of spontaneous circulation (ROSC)-in fact, quite the contrary is true. Along with identifying and appropriately treating the precipitating cause, various components of the post-cardiac arrest syndrome also require diligent observation and management, including post-cardiac arrest neurologic injury and myocardial dysfunction, systemic ischemia-reperfusion phenomenon with potential consequent multiorgan failure, and the various sequelae of critical illness. There is growing evidence that an early invasive approach to coronary reperfusion with percutaneous coronary intervention, together with active targeted temperature management and optimization of hemodynamic, ventilator, and metabolic parameters, may improve survival and neurologic outcomes in cardiac arrest survivors. Neuroprognostication is complex, as are survivorship issues and long-term rehabilitation. Our paramedics, emergency physicians, and resuscitation specialists are all to be congratulated for ever-increasing success with ROSC… but now the real work begins.

Esophageal Heat Transfer for Patient Temperature Control and Targeted Temperature Management.

Controlling patient temperature is important for a wide variety of clinical conditions. Cooling to normal or below normal body temperature is often performed for neuroprotection after ischemic insult (e.g. hemorrhagic stroke, subarachnoid hemorrhage, cardiac arrest, or other hypoxic injury). Cooling from febrile states treats fever and reduces the negative effects of hyperthermia on injured neurons. Patients are warmed in the operating room to prevent inadvertent perioperative hypothermia, which is known to cause increased blood loss, wound infections, and myocardial injury, while also prolonging recovery time. There are many reported approaches for temperature management, including improvised methods that repurpose standard supplies (e.g., ice, chilled saline, fans, blankets) but more sophisticated technologies designed for temperature management are typically more successful in delivering an optimized protocol. Over the last decade, advanced technologies have developed around two heat transfer methods: surface devices (water blankets, forced-air warmers) or intravascular devices (sterile catheters requiring vascular placement). Recently, a novel device became available that is placed in the esophagus, analogous to a standard orogastric tube, that provides efficient heat transfer through the patient's core. The device connects to existing heat exchange units to allow automatic patient temperature management via a servo mechanism, using patient temperature from standard temperature sensors (rectal, Foley, or other core temperature sensors) as the input variable. This approach eliminates vascular placement complications (deep venous thrombosis, central line associated bloodstream infection), reduces obstruction to patient access, and causes less shivering when compared to surface approaches. Published data have also shown a high degree of accuracy and maintenance of target temperature using the esophageal approach to temperature management. Therefore, the purpose of this method is to provide a low-risk alternative method for controlling patient temperature in critical care settings.

The esophageal cooling device: A new temperature control tool in the intensivist's arsenal.

BACKGROUND: Therapeutic hypothermia has been demonstrated to improve neurological outcome in comatose survivors of cardiac arrest. Current temperature control modalities however, have several limitations. Exploring innovative methods of temperature management has become a necessity. METHODS: We describe the first use of a novel esophageal cooling device as a sole modality for hypothermia induction, maintenance and rewarming in a series of four postcardiac arrest patients. The device was inserted in a manner similar to standard orogastric tubes and connected to an external heat exchange unit. RESULTS: A mean cooling rate of 0.42 °C/hr (SD ± 0.26) was observed. An average of 4 hr 24 min (SD ± 2 hr 6 min) was required to reach target temperature, and this was maintained 90.25% (SD ± 16.20%) of the hypothermia protocol duration. No adverse events related to device use were encountered. Questionnaires administered to ICU nursing staff regarding ease-of-use of the device and its performance were rated as favorable. CONCLUSIONS: When used as a sole modality, objective performance parameters of the esophageal-cooling device were found to be comparable to standard temperature control methods. More research is required to further quantify efficacy, safety, assess utility in other patient populations, and examine patient outcomes with device use in comparison to standard temperature control modalities.

Temperature control in critically ill patients with a novel esophageal cooling device: a case series.

BACKGROUND: Mild hypothermia and fever control have been shown to improve neurological outcomes post cardiac arrest. Common methods to induce hypothermia include body surface cooling and intravascular cooling; however, a new approach using an esophageal cooling catheter has recently become available. METHODS: We report the first three cases of temperature control using an esophageal cooling device (ECD). The ECD was placed in a similar fashion to orogastric tubes. Temperature reduction was achieved by connecting the ECD to a commercially available external heat exchange unit (Blanketrol Hyperthermia - Hypothermia System). RESULTS: The first patient, a 54 year-old woman (86 kg) was admitted after resuscitation from an out-of-hospital non-shockable cardiac arrest. Shortly after admission, she mounted a fever peaking at 38.3 °C despite administration of cold intravenous saline and application of cooling blankets. ECD utilization resulted in a temperature reduction to 35.7 °C over a period of 4 h. She subsequently recovered and was discharged home at day 23. The second patient, a 59 year-old man (73 kg), was admitted after successful resuscitation from a protracted out-of hospital cardiac arrest. His initial temperature was 35 °C, but slowly increased to 35.8 °C despite applying a cooling blanket and ice packs. The ECD was inserted and a temperature reduction to 34.8 °C was achieved within 3 h. The patient expired on day 3. The third patient, a 47 year-old man (95 kg) presented with a refractory fever secondary to necrotizing pneumonia in the postoperative period after coronary artery bypass grafting. His fever persisted despite empiric antibiotics, antipyretics, cooling blankets, and ice packs. ECD insertion resulted in a decrease in temperature from 39.5 to 36.5 °C in less than 5 h. He eventually made a favorable recovery and was discharged home after 59 days. In all 3 patients, device placement occurred in under 3 min and ease-of-use was reported as excellent by nursing staff and physicians. CONCLUSIONS: The esophageal cooling device was found to be an effective temperature control modality in this small case series of critically ill patients. Preliminary data presented in this report needs to be confirmed in large randomized controlled trials comparing its efficacy and safety to standard temperature control modalities.