Severe heat stroke with multiple organ dysfunction

In a case report recently published in Critical Care, Broessner and coworkers [1] claim to have successfully treated a patient with heat stroke by using a specific cooling device. We should like to raise some important issues. First, why were nonsteroidal anti-inflammatory drugs (NSAIDs) used acutely as a primary cooling method? No evidence supports the use of NSAIDs to reduce temperature during the acute phase of heat stroke. Moreover, they can be deleterious to the patient [2]. A rationale for the use of NSAIDs should be provided. Second, why were conventional cooling techniques terminated after 8 hours when the graph (Figure 1 in the report by Broessner and coworkers [1]) indicates that body temperature was effectively lowered to below 39°C (the initial goal in treatment of heat stroke)? We question the cooling technique, because aggressive conventional cooling in the intensive care unit should achieve 39°C within 1 hour [3]. Third, were NSAIDs continued during use of the CoolGard(® )device? If so, then it would be difficult to assess the physiologic significance and effectiveness of the cooling device. Finally, is it not likely that an ongoing infection (in this case sinusitis) could have played some causative role with respect to the severity and complications associated with the heat illness? Although the initial computed tomographic diagnosis and physical examination did not reveal any pathology, it was later reported that computed tomography was consistent with sinusitis maxillaris and aspiration pneumonia. These infections might have had an impact on the responses and later complications, but this possibility was not discussed as a potential contributing factor.