TY - JOUR
AB - Abstract Reports of iatrogenic cold thermal injuries are rare in the literature. Conductive cooling devices, typically employed for their neuroprotective effects, use conductive hydrogel pads to achieve rapid and precise temperature control approaching the level of water immersion. Despite a number of built-in safeguards, prolonged or improper use of these devices can lead to significant thermal injury. To the best of their knowledge, the authors describe the first report of a significant iatrogenic full-thickness injury caused by the use of a surface cooling system in a patient who had recently suffered a cerebrovascular accident. The patient required transfer to the authors’ tertiary burn care facility for excisional debridement and coverage with extensive split-thickness skin grafting to the chest, flank, and thighs. The grafts achieved nearly complete take and the patient was ultimately discharged to a rehabilitation facility with improving neurological condition. The role of therapeutic hypothermia in postcardiac arrest patients and normothermia in patients stroke or traumatic brain injury has been studied for decades. New computer-regulated cooling devices allow for rapid and precise temperature control and have improved patient outcomes when compared with standard cooling therapies.1 These dry immersive devices utilizing conductive cooling pads achieve temperature control comparable with that of water immersion.2 These devices have multiple safeguards and monitoring features built into the system and come with specific guidelines for use provided by the manufacturer. The purpose of this article was to alert health-care providers to the potential harm that can result from prolonged or improper use of conductive cooling devices. We present an unusual case of an iatrogenic full-thickness frostbite injury caused by a surface cooling system in a patient following a cerebral infarction. CASE PRESENTATION A 41-year-old Caucasian male with a medical history of atrial fibrillation presented to an outside hospital following an acute left-sided middle cerebral artery infarction. The patient was initially treated with thrombectomy, which was complicated by a hemorrhagic stroke and increased intracranial pressure necessitating a hemicraniectomy. As a result of his extensive neurological injuries, the patient began to experience central fevers. In an attempt to mitigate the neurotoxic effects of prolonged fever, the Arctic Sun® 5000 Temperature Management System (Medivance, Louisville, CO) was employed and placed directly on the chest, trunk, and thighs. Upon removal of the gel conductive cooling pads on day 5, extensive areas of ecchymosis were discovered underlying the sites of pad placement. The cooling device was discontinued at this time. Over the course of the following week, the zone of injury began to demarcate and upon recognition of full-thickness cold injury, the patient was transferred to our institution for wound management and tertiary burn care. Upon arrival, the patient was noted to have well-defined areas of full-thickness injury over bilateral thighs, the right chest, and the flank approximating 7% TBSA. The patient’s thighs were noted to have relatively symmetric and uniform areas of full-thickness necrosis with central eschar extending to the fascia (Figure 1). The flank had similar full-thickness injury with more superficial and uneven injury over the ribs, which did not penetrate beyond subcutaneous tissue (Figure 2). The patient was taken to the operating room and underwent debridement of subcutaneous tissue and fascia to the level of viable underlying muscle on the thigh and debridement of subcutaneous tissue on the flank. Five days later, the patient was taken back for split-thickness skin grafting to provide definitive coverage. Skin was harvested from bilateral thighs using a dermatome set at 10 mm thickness, meshed at a 1:1.5 ratio, and covered an area of 600 cm2. Conformant impregnated with bacitracin ointment was applied and staples were used to hold the grafts in place (Figure 3). Figure 1. View largeDownload slide A. Full-thickness cold injury at site of hydrogel pad placement on left thigh. B. Postoperative appearance following cutaneous and fascial debridement with exposed viable fascia and muscle. Figure 1. View largeDownload slide A. Full-thickness cold injury at site of hydrogel pad placement on left thigh. B. Postoperative appearance following cutaneous and fascial debridement with exposed viable fascia and muscle. Figure 2. View largeDownload slide A. Right flank and chest with irregular areas of full- and partial-thickness necrosis. B. Postoperative appearance following debridement of necrotic areas and preservation of salvageable surrounding tissue. Figure 2. View largeDownload slide A. Right flank and chest with irregular areas of full- and partial-thickness necrosis. B. Postoperative appearance following debridement of necrotic areas and preservation of salvageable surrounding tissue. Figure 3. View largeDownload slide Right thigh following split-thickness skin graft and conformant dressing. Figure 3. View largeDownload slide Right thigh following split-thickness skin graft and conformant dressing. The patient did well postoperatively with approximately 90% graft take to all sites with exception of a small area over the right flank. This area was later closed with 3 vertical mattress sutures, healing by tertiary intention. The patient experienced no infections or donor-site morbidity during his postoperative course. As intracerebral edema declined and recovery ensued, the patient began to regain cognitive function and movement of his right side. The patient was discharged on hospital day 11 to an inpatient rehabilitation facility, requiring minimal continued wound care for his injuries. DISCUSSION In this article, we present a case of an iatrogenic full-thickness frostbite injury due to an unusual etiology. To the best of our knowledge, this degree and extent of injury has never been reported as result of a therapeutic surface cooling device. The Arctic Sun cooling system uses 3 conductive gel pads, which are designed to mimic the heat transfer efficiency of water immersion. According to the manufacturer, the pads are designed to remain in place for up to 5 days. However, examining the skin underneath the pads every 4 to 6 hours is recommended. If the patient does not reach the target temperature within 4 hours or if the temperature is below 50 degrees Fahrenheit for 8 consecutive hours, the device should be discontinued.3 When used correctly, new conductive cooling systems can provide a significantly more efficient heat transfer than traditional cooling blankets or ice, approaching the level of control achieved with intravascular cooling techniques.2 A recent comparison study found that the Arctic Sun cooling system allowed for more precise temperature control when inducing hypothermia in comatose survivors of out-of-hospital cardiac arrest compared with traditional cooling blankets and ice.3 With similar fine tailoring of body temperatures compared with catheter-based core-directed cooling methods, surface systems are reported to have the advantage of noninvasiveness with significantly improved ease of use in providers with less specialized training. In addition, of a total of 64 patients, there were no reported adverse skin events in the patients of either group.4 Although rare, scattered case reports have described iatrogenic cold thermal injuries caused by various cooling devices. In a recent series, 4 patients undergoing cold cap therapy for the prevention of chemotherapy-induced-alopecia developed mild thermal injuries as a result of the therapy. In all 4 patients, the injuries were superficial and improved with conservative topical therapy.5 An extensive literature search revealed no previously reported cases of iatrogenic frostbite caused by a surface conductive cooling system, many concluding the therapy to be highly effective with no repercussions on the skin.6 In our case, the patient was exposed to the Arctic Sun cooling system for 5 consecutive days and sustained full-thickness skin necrosis due to the cold thermal injury at the sites of pad placement. While uncommon, iatrogenic cold thermal injury can occur with prolonged exposure or improper use of cooling devices. It is important to always follow the manufacturer’s safety protocols for use and to ensure that institutional guidelines meet similar standards. While one may not typically expect the well-perfused truncal regions of the body with low surface area relative to the digits to be susceptible to this complication, our case suggests a need for a higher degree of vigilance when using this type of device. In this case, prolonged exposure to the cooling pads in an obtunded patient led to full-thickness skin necrosis, which necessitated soft-tissue debridement and skin grafting. Frequent skin checks and alternating cooling contact surfaces are important when using any cooling system and may help prevent further complications in an already vulnerable patient population. REFERENCES 1. Mayer SA , Kowalski RG , Presciutti M , et al. . Clinical trial of a novel surface cooling system for fever control in neurocritical care patients . Crit Care Med 2004 ; 32 : 2508 – 15 . Google Scholar CrossRef Search ADS PubMed 2. 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 . Google Scholar CrossRef Search ADS PubMed 3. Arctic Sun 5000 clinical education training workbook . Available from http://www.medivance.com/pdf/MT08204.pdf. Accessed June 02, 2016 . 4. Heard KJ , Peberdy MA , Sayre MR , et al. . A randomized controlled trial comparing the Arctic Sun to standard cooling for induction of hypothermia after cardiac arrest . Resuscitation 2010 ; 81 : 9 – 14 . Google Scholar CrossRef Search ADS PubMed 5. Belum VR , de Barros Silva G , Laloni MT , et al. . Cold thermal injury from cold caps used for the prevention of chemotherapy-induced alopecia . Breast Cancer Res Treat 2016 ; 157 : 395 – 400 . Google Scholar CrossRef Search ADS PubMed 6. Haugk M , Sterz F , Grassberger M , et al. . Feasibility and efficacy of a new non-invasive surface cooling device in post-resuscitation intensive care medicine . Resuscitation 2007 ; 75 : 76 – 81 . Google Scholar CrossRef Search ADS PubMed © American Burn Association 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Iatrogenic Full-Thickness Frostbite Injury Caused by the Use of a Conductive Cooling Device
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0000000000000623
DA - 2018-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/iatrogenic-full-thickness-frostbite-injury-caused-by-the-use-of-a-sDi7030Iv0
SP - 843
EP - 845
VL - 39
IS - 5
DP - DeepDyve
ER -