Progress in shivering control

Hypothermia is a potent neuroprotectant and induced hypothermia holds great promise as a therapy for acute neuronal injury. Thermoregulatory responses, most notably shivering, present major obstacles to therapeutic temperature management. A review of thermoregulatory physiology and strategies aimed at controlling physiologic responses to hypothermia is presented.

Meperidine and skin surface warming additively reduce the shivering threshold: a volunteer study

Introduction

Mild therapeutic hypothermia has been shown to improve outcome for patients after cardiac arrest and may be beneficial for ischaemic stroke and myocardial ischaemia patients. However, in the awake patient, even a small decrease of core temperature provokes vigorous autonomic reactions–vasoconstriction and shivering–which both inhibit efficient core cooling. Meperidine and skin warming each linearly lower vasoconstriction and shivering thresholds. We tested whether a combination of skin warming and a medium dose of meperidine additively would reduce the shivering threshold to below 34°C without producing significant sedation or respiratory depression.

Methods

Eight healthy volunteers participated on four study days: (1) control, (2) skin warming (with forced air and warming mattress), (3) meperidine (target plasma level: 0.9 μg/ml), and (4) skin warming plus meperidine (target plasma level: 0.9 μg/ml). Volunteers were cooled with 4°C cold Ringer lactate infused over a central venous catheter (rate ≈ 2.4°C/hour core temperature drop). Shivering threshold was identified by an increase of oxygen consumption (+20% of baseline). Sedation was assessed with the Observer's Assessment of Alertness/Sedation scale.

Results

Control shivering threshold was 35.5°C ± 0.2°C. Skin warming reduced the shivering threshold to 34.9°C ± 0.5°C (p = 0.01). Meperidine reduced the shivering threshold to 34.2°C ± 0.3°C (p < 0.01). The combination of meperidine and skin warming reduced the shivering threshold to 33.8°C ± 0.2°C (p < 0.01). There were no synergistic or antagonistic effects of meperidine and skin warming (p = 0.59). Only very mild sedation occurred on meperidine days.

Conclusion

A combination of meperidine and skin surface warming reduced the shivering threshold to 33.8°C ± 0.2°C via an additive interaction and produced only very mild sedation and no respiratory toxicity.

Lipid mobilization of long-distance migrant birds in vivo: the high lipolytic rate of ruff sandpipers is not stimulated during shivering

For long migrations, birds must rely on high flux capacities at all steps of lipid metabolism, from the mobilization of adipose reserves to fatty acid oxidation in flight muscle mitochondria. Substrate kinetics and indirect calorimetry were used to investigate key parameters of lipid metabolism in a highly aerobic shorebird: the ruff sandpiper Philomachus pugnax. In this study, we have quantified the effects of cold exposure because such measurements are presently impossible during flight. Lipolytic rate was monitored by continuous infusion of 2-[3H]-glycerol and lipid oxidation by respirometry. Plasma lipid concentrations (non-esterified fatty acids, neutral lipids and phospholipids) and their fatty acid composition were also measured to assess whether cold exposure causes selective metabolism of specific lipids. Results show that shivering leads to a 47% increase in metabolic rate (44.4±3.8 ml O2kg–1min–1 to 65.2±8.1 ml O2kg–1 min–1), almost solely by stimulating lipid oxidation (33.3± 3.3 ml O2 kg–1min–1 to 48.2±6.8 ml O2kg–1 min–1) because carbohydrate oxidation remains close to 11.5± 0.5 ml O2 kg–1min–1. Sandpipers support an unusually high lipolytic rate of 55–60 μmol glycerol kg–1 min–1. Its stimulation above thermoneutral rates is unnecessary during shivering when the birds are still able to re-esterify 50% of released fatty acids. No changes in plasma lipid composition were observed, suggesting that cold exposure does not lead to selective metabolism of particular fatty acids. This study provides the first measurements of lipolytic rate in migrant birds and shows that their capacity for lipid mobilization reaches the highest values measured to date in vertebrates. Extending the limits of conventional lipid metabolism has clearly been necessary to achieve long-distance migrations.

Cold-induced heat production preceding shivering

Individual changes in heat production and body temperature were studied in response to cold exposure, prior to shivering. The subjects ten women (seven men) were of normal weight, had a mean age of 23 (SD 3) years and average BMI 22·2 (SD 1·6) Kg/m2. They were lying supine under thermoneutral conditions for 30 min and were subsequently exposed to air of 15°C until shivering occurred. Heat production was measured with a ventilated hood. Body composition was measured with underwater weighing and 2H dilution. Body temperatures were measured with thermistors. Heat production during cold exposure prior to shivering increased and reached a plateau. Skin temperature decreased and did not reach a plateau during the test period. The non-shivering interval (NSI) ranged from 20 to 148 min, was not related to body composition and was not significantly different between women (81 (sd 15) min) and men (84 (sd 34) min). NSI was negatively related to skin temperature (r2 0·44, P=0·004), and skin temperature was related to heat production (r2 0·39, P=0·007) In conclusion, subjects with a relatively large heat production during cold exposure maintained a relatively high skin temperature but showed a short NSI, independent of differences in body composition.

Thermal responses for men with different fat compositions during immersion in cold water at two depths: prediction versus observation

A cold thermoregulatory model (CTM) was applied to data from partially immersed subjects divided into normal (NF) or low fat (LF) groups in order to validate CTM during immersion at two depths and to examine mechanisms underlying the individual differences. CTM defines thermal characteristics, e.g. surface area and maximal shivering intensity, using height, weight, fat %, age and VO(2max). Ten clothed subjects, 5 NF (15-19%) and 5 LF (8.1-14.7%), were immersed in both 10 and 15 degrees C water at chest (CH) and waist (WA) level. Environmental and clothing inputs for CTM were weighted to adjust for the ratio of skin surface area covered by either air or water at various immersion depths. Predicted core temperature (Tc) responses for each individual trial were compared with measured data. There were no significant differences (P > 0.05) between measured Tc and predicted Tc for NF at all four conditions. In contrast, for the LF group, the predicted Tc responses were all higher than measured (P < 0.05). However, predicted Tc agreed closer with measured Tc for LF when leg muscle blood flow was increased in the simulation. This suggests that blood flow may contribute to the rapid decline in Tc observed in LF and its variance may cause in part the individual differences in Tc responses. CTM predicts Tc responses to immersion at various depths with acceptable accuracy for NF individuals in this study and can be adapted to non-uniform environments.

Hypothermia in patients with chronic spinal cord injury

DESIGN

Retrospective analysis of medical records.

BACKGROUND/OBJECTIVES

To determine frequency and degree of hypothermic episodes in patients with chronic spinal cord injury (SCI).

SETTING

Veterans Administration Medical Center.

METHODS

Research involved analysis of body temperature records of 50 chronic patients with tetraplegia. All patients were men with a length of injury of 19 +/- 6 years. Mean age was 53 +/- 15 (SD) years. Data were derived from the computerized patient record database system of the Veterans Administration Medical Center. Results were classified into 3 groups: (a) hypothermia (< 95 degrees F), (b) subnormal temperature (< 97.7 degrees F), and normal temperatures (97.7 degrees F to 98.4 degrees F). Body temperature was recorded during hospitalization (minimum duration of 30 days) using an oral probe twice a day. Ambient temperature was controlled by a central air-conditioning system and maintained at 72 degrees F to 74 degrees F.

RESULTS

A total of 867 measurements of body temperature were evaluated; normal temperature was recorded 298 times (35%), subnormal temperature was recorded 544 times (63%), and hypothermia was recorded 25 times (3%). There were 15 patients with 30 hypothermic episodes; subnormal temperature was found in all 50 patients from 1 to 47 times. Regression analysis of age and duration of SCI showed a nonsignificant relationship with body temperature.

CONCLUSIONS

Our data suggest that patients with tetraplegia after SCI have significant dysfunction of thermoregulation associated with frequent episodes of subnormal body temperature in a normal ambient environment. Further studies are needed to evaluate possible consequences of low temperatures on the general health of patients and to develop preventive interventions.

Individual Variability in the Peripheral and Core Interthreshold Zones

The purpose of the study was to investigate the degree of subject variability in the peripheral and core temperature thresholds of the onset of shivering and sweating. Nine healthy young male subjects participated in three trials. In the first two trials, wearing only shorts, they were exposed to air temperatures of 5 degrees C and 40 degrees C until the onset of shivering and sweating, respectively. In the second experiment, subjects wore a water perfused suit that was perfused with 25 degrees C water at a rate of 600 cc/min. They exercised on an ergometer at 50% of their maximum work rate for 10-15 min. At the onset of sweating, the exercise was terminated, and they remained seated until the onset of shivering, as reflected in oxygen uptake. In the first two trials, rectal temperature (Tre) was stable, despite displacements in skin temperature (Tsk), whereas in the third trial, Tsk (measured at four sites) was almost constant (30-32 degrees C), and the thermoregulatory responses were initiated due to changes in Tre alone. The results of the first two trials established the peripheral interthreshold zone, whereas the results of the third trial established the core interthreshold zone. The results demonstrated individual variability in the peripheral and core interthreshold zones, a proportional correlation between both zones (r=0.87), and a relatively higher contribution of adiposity in both zones as compared with those of other non-thermal factors such as height, weight, body surface area, surface area-to mass ratio, and the maximum work load.

Early social isolation alters behavioral and physiological responses to an endotoxin challenge in piglets

Psychosocial stress in the form of maternal deprivation and social isolation during early postnatal life induces persistent alterations in behavioral and physiological mechanisms of adaptation. One consequence may be an increased susceptibility to diseases in later life. Therefore, the aim of the present study was to investigate in domestic piglets the effects of a repeated social isolation (2 h daily from day 3 to day 11 of age) on behavioral, endocrine and immune responses to an endotoxin challenge with lipopolysaccharide (LPS) 1 day or 45 days after the isolation period. Peripheral LPS administration caused serious sickness behavior (somnolence, shivering, vomiting) and provoked profound increases in circulating tumor necrosis factor-alpha (TNF-alpha), ACTH and cortisol concentrations. The prior social isolation treatment enhanced signs of sickness and impaired suckling behavior. Early isolated piglets responded to LPS by an increase of shivering on day 12 and by increased vomiting on day 56 compared to controls. Further, there were considerable delays and reductions of time isolated piglets spent suckling on day 12. The repeated isolation stressor diminished TNF-alpha increases after LPS, whereas stress hormone levels were not significantly affected by isolation treatment. Finally, stronger relationships between signs of sickness and physiological measures were revealed in early isolated piglets. The duration of somnolence in isolated piglets was related to changes of cortisol and TNF-alpha concentrations, and the highest impact on duration of shivering was found for changes in cortisol and corticosteroid binding globulin levels. The present results suggest a sustained adaptive sensitization of coping with infection by social stress experience during early development in piglets.

Heat production and body temperature during cooling and rewarming in overweight and lean men

OBJECTIVE

To compare overweight and lean subjects with respect to thermogenesis and physiological insulation in response to mild cold and rewarming.

RESEARCH METHODS AND PROCEDURES

Ten overweight men (mean BMI, 29.2 +/- 2.8 kg/m(2)) and 10 lean men (mean BMI, 21.1 +/- 2.0 kg/m(2)) were exposed to cold air for 1 hour, followed by 1 hour of rewarming. Body composition was determined by hydrodensitometry and deuterium dilution. Heat production and body temperatures were measured continuously by indirect calorimetry and thermistors, respectively. Muscle activity was recorded using electromyography.

RESULTS

In both groups, heat production increased significantly during cooling (lean, p = 0.004; overweight, p = 0.006). The increase was larger in the lean group compared with the overweight group (p = 0.04). During rewarming, heat production returned to baseline in the overweight group and stayed higher compared with baseline in the lean group (p = 0.003). The difference in heat production between rewarming and baseline was larger in the lean (p = 0.01) than in the overweight subjects. Weighted body temperature of both groups decreased during cold exposure (lean, p = 0.002; overweight, p < 0.001) and did not return to baseline during rewarming.

DISCUSSION

Overweight subjects showed a blunted mild cold-induced thermogenesis. The insulative cold response was not different among the groups. The energy-efficient response of the overweight subjects can have consequences for energy balance in the long term. The results support the concept of a dynamic heat regulation model instead of temperature regulation around a fixed set point.

Mole-rats from higher altitudes have greater thermoregulatory capabilities

Subterranean mammals (those that live and forage underground) inhabit a challenging microenvironment, with high levels of carbon dioxide and low levels of oxygen. Consequently, they have evolved specialised morphological and physiological adaptations. For small mammals that inhabit high altitudes, the effects of cold are compounded by low oxygen partial pressures. Hence, subterranean mammals living at high altitudes are faced with a uniquely demanding physiological environment, which presumably necessitates additional physiological adjustments. We examined the thermoregulatory capabilities of two populations of Lesotho mole-rat Cryptomys hottentotus mahali that inhabit a 'low' (1600 m) and a 'high' (3200 m) altitude. Mole-rats from the high altitude had a lower temperature of the lower critical point, a broader thermoneutral zone, a lower thermal conductance and greater regulatory non-shivering thermogenesis than animals from the lower altitude. However, minimum resting metabolic rate values were not significantly different between the populations and were low compared with allometric predictions. We suggest that thermoregulatory costs may in part be met by animals maintaining a low resting metabolic rate. High-altitude animals may adjust to their cooler, more oxygen-deficient environment by having an increased non-shivering thermogenesis whilst maintaining low thermal conductance.

Role of glucagon in the control of heat production in ducklings

Glucagon is known to be a central modulator of neural activity and a peripheral thermogenic effect. The purpose of this study was to better understand the role of glucagon in the control of heat production, shivering and particularly as a mediator of nonshivering thermogenesis (NST) in ducklings. In order to study the mechanism of NST, an intracerebroventricular (i.c.v.) injection of glucagon (10(-7) M) in to thermoneutral (TN), chronically glucagon treated (GT) and cold acclimatized (CA) ducklings exposed to acute cold (4 degrees C) or a thermoneutrality (25 degrees C), was performed. At 25 degrees C ambient temperature (Ta), the metabolic rate (MR) remained unchanged after glucagon injection. At 4 degrees C Ta i.c.v. glucagon injection, no significant change in MR was observed in GT and CA ducklings during 160 min of cold exposure, whereas there was 63% decrease in MR in (TN) ducklings (5.02 +/- 0.1 2 vs 7.91 +/- 0.1 4 W/kg(-1) p < 0.05). Shivering activity was completely suppressed in TN and GT ducklings after glucagon administration. The NST was estimated to be 3.26 W/kg. This findings suggest that glucagon administered into the brain has no thermogenic effect but could be involved in the central control of somatic motricity, and here we demonstrated for the first time, of our knowledge, that central glucagon have a role in the development of nonshivering thermogenesis during prolonged cold via an inhibition of shivering in birds.

Shivering in the cold: from mechanisms of fuel selection to survival

In cold-exposed adult humans, significant or lethal decreases in body temperature are delayed by reducing heat loss via peripheral vasoconstriction and by increasing rates of heat production via shivering thermogenesis. This brief review focuses on the mechanisms of fuel selection responsible for sustaining long-term shivering thermogenesis. It provides evidence to explain large discrepancies in fuel selection measurements among shivering studies, and it proposes links between choices in fuel selection mechanism and human survival in the cold. Over the last decades, a number of studies have quantified the contributions of carbohydrate (CHO) and lipid to total heat generation. However, the exact contributions of these fuels still remain unclear because of large differences in fuel selection measurements even at the same metabolic rate. Recent advances on the mechanisms of fuel selection during shivering provide some plausible explanations for these discrepancies between shivering studies. This new evidence indicates that muscles can sustain shivering over several hours using a variety of fuel mixtures achieved by modifying diet (changing the size of CHO reserves) or by changing muscle fiber recruitment (increasing or decreasing the recruitment of type II fibers). From a practical perspective, how does the choice of fuel selection mechanism affect human survival in the cold? Based on a glycogen-depletion model, estimates of shivering endurance show that, whereas the oxidation of widely different fuel mixtures does not improve survival time, the selective recruitment of fuel-specific muscle fibers provides a substantial advantage for cold survival. By combining fundamental research on fuel metabolism and applied strategies to improve shivering endurance, future research in this area promises to yield important new information on what limits human survival in the cold.

Complement, fetal antigen, and shaking rigors in parturients

OBJECTIVES

To assess the relationship, if any, between complement, fetal antigen, and shaking rigors during labor and delivery.

METHODS

We recruited 13 volunteers for serial blood sampling during labor and childbirth.

RESULTS

Complement levels had a small but significant drop (11-15%) immediately following childbirth but had no association with fetal antigen levels or shaking rigors. Fetal antigen levels failed to show any consistent relationship with shaking rigors or the labor and delivery process.

CONCLUSION

Shaking rigors do not appear to be associated with changes in either complement or fetal antigen levels. Complement levels remain stable during labor but drop immediately following birth.

UCP1 is essential for adaptive adrenergic nonshivering thermogenesis

Participation of brown adipose tissue [through the action of the uncoupling protein-1 (UCP1)] in adaptive adrenergic nonshivering thermogenesis is recognized, but the existence of a response to adrenergic stimulation in UCP1-ablated mice implies that a mechanism for an alternative adaptive adrenergic thermogenesis may exist. Here, we have used UCP1-ablated mice to examine the existence of an alternative adaptive adrenergic nonshivering thermogenesis, examined as the oxygen consumption response to systemically injected norepinephrine into anesthetized or conscious mice acclimated to different temperatures. We confirm that UCP1-dependent adrenergic nonshivering thermogenesis is adaptive, but we demonstrate that the adrenergic UCP1-independent thermogenesis is not recruitable by cold acclimation. Thus, at least in the mouse, no other proteins or enzymatic pathways exist that can participate in or with time take over the UCP1 mediation of adaptive adrenergic nonshivering thermogenesis, even in the total absence of UCP1. UCP1 is thus the only protein capable of mediating cold acclimation-recruited adaptive adrenergic nonshivering thermogenesis.

Thermal effects of whole head submersion in cold water on nonshivering humans

This study isolated the effect of whole head submersion in cold water, on surface heat loss and body core cooling, when the confounding effect of shivering heat production was pharmacologically eliminated. Eight healthy male subjects were studied in 17°C water under four conditions: the body was either insulated or uninsulated, with the head either above the water or completely submersed in each body-insulation subcondition. Shivering was abolished with buspirone (30 mg) and meperidine (2.5 mg/kg), and subjects breathed compressed air throughout all trials. Over the first 30 min of immersion, exposure of the head increased core cooling both in the body-insulated conditions (head out: 0.47 ± 0.2°C, head in: 0.77 ± 0.2°C; P < 0.05) and the body-exposed conditions (head out: 0.84 ± 0.2°C and head in: 1.17 ± 0.5°C; P < 0.02). Submersion of the head (7% of the body surface area) in the body-exposed conditions increased total heat loss by only 10%. In both body-exposed and body-insulated conditions, head submersion increased core cooling rate much more (average of 42%) than it increased total heat loss. This may be explained by a redistribution of blood flow in response to stimulation of thermosensitive and/or trigeminal receptors in the scalp, neck and face, where a given amount of heat loss would have a greater cooling effect on a smaller perfused body mass. In 17°C water, the head does not contribute relatively more than the rest of the body to surface heat loss; however, a cold-induced reduction of perfused body mass may allow this small increase in heat loss to cause a relatively larger cooling of the body core.

Contribution of thermal and nonthermal factors to the regulation of body temperature in humans

The set point has been used to define the regulated level of body temperature, suggesting that displacements of core temperature from the set point initiate heat production (HP) and heat loss (HL) responses. Human and animal experiments have demonstrated that the responses of sweating and shivering do not coincide at a set point but rather establish a thermoeffector threshold zone. Neurophysiological studies have demonstrated that the sensor-to-effector pathways for HP and HL overlap and, in fact, mutually inhibit each other. This reciprocal inhibition theory, presumably reflecting the manner in which thermal factors contribute to homeothermy in humans, does not incorporate the effect of nonthermal factors on temperature regulation. The present review examines the actions of these nonthermal factors within the context of neuronal models of temperature regulation, suggesting that examination of these factors may provide further insights into the nature of temperature regulation. It is concluded that, although there is no evidence to doubt the existence of the HP and HL pathways reciprocally inhibiting one another, it appears that such a mechanism is of little consequence when comparing the effects of nonthermal factors on the thermoregulatory system, since most of these factors seem to exert their influence in the region after the reciprocal cross-inhibition. At any given moment, both thermal and several nonthermal factors will be acting on the thermoregulatory system. It may, therefore, not be appropriate to dismiss the contribution of either when discussing the regulation of body temperature in humans.

The effect of a commercially available burn-cooling blanket on core body temperatures in volunteers

BACKGROUND

Cooling of burns is one of the oldest therapies, yet there are concerns that excessive cooling may result in hypothermia.

OBJECTIVES

To determine the effects of surface cooling with a commercially available cooling blanket on the core temperatures of volunteers and to test the ability of the cooling blanket to reduce water evaporation from plastic containers. The null hypothesis was that rectal temperatures would not be reduced by surface cooling and that the cooling blanket would reduce evaporative water loss.

METHODS

This was a prospective, noncomparative, interventional study. Ten healthy adult volunteers were recruited. Subjects were completely unclothed, and their entire body (excluding the head) was circumferentially wrapped with a commercially available gel-soaked cooling blanket at room temperature. A rectal temperature probe was inserted, and continuous monitoring of vital signs was performed during a 30-minute period. In addition, six plastic containers were filled with 50 mL of room-temperature water, half of which were covered with the cooling blanket. The amount of water remaining within the containers was measured at hourly intervals over four hours.

RESULTS

The subjects' mean age was 38 years; 50% were female. There were no significant changes in core body temperatures over time in any of the study subjects. Mean (95% confidence intervals [CI]) core temperatures at the beginning and at the end of the study period were 37.2 degrees C (95% CI = 37.0 degrees C to 37.4 degrees C) and 37.3 degrees C (95% CI = 37.1 degrees C to 37.5 degrees C), respectively. Water evaporation in the blanket-covered containers was less than in the uncovered containers.

CONCLUSIONS

The authors conclude that covering healthy volunteers with a room temperature burn-cooling blanket for 30 minutes does not result in hypothermia and that the cooling blanket reduces evaporative water loss.

DI. Ondansetron does not reduce the shivering threshold in healthy volunteers

BACKGROUND

Ondansetron, a serotonin-3 receptor antagonist, reduces postoperative shivering. Drugs that reduce shivering usually impair central thermoregulatory control, and may thus be useful for preventing shivering during induction of therapeutic hypothermia. We determined, therefore, whether ondansetron reduces the major autonomic thermoregulatory response thresholds (triggering core temperatures) in humans.

METHODS

Control (placebo) and ondansetron infusions at the target plasma concentration of 250 ng ml(-1) were studied in healthy volunteers on two different days. Each day, skin and core temperatures were increased to provoke sweating; then reduced to elicit peripheral vasoconstriction and shivering. We determined the core-temperature sweating, vasoconstriction and shivering thresholds after compensating for changes in mean-skin temperature. Data were analysed using t-tests and presented as means (sds); P<0.05 was taken as significant.

RESULTS

Ondensetron plasma concentrations were 278 (57), 234 (55) and 243 (58) ng ml(-1) at the sweating, vasoconstriction and shivering thresholds, respectively; these corresponded to approximately 50 mg of ondansetron which is approximately 10 times the dose used for postoperative nausea and vomiting. Ondansetron did not change the sweating (control 37.4 (0.4) degrees C, ondansetron 37.6 (0.3) degrees C, P=0.16), vasoconstriction (37.0 (0.5) degrees C vs 37.1 (0.3) degrees C; P=0.70), or shivering threshold (36.3 (0.5) degrees C vs 36.3 (0.6) degrees C; P=0.76). No sedation was observed on either study day.

CONCLUSIONS

/b>. Ondansetron appears to have little potential for facilitating induction of therapeutic hypothermia.

Maternal and Newborn Outcomes Related to Maternal Warming During Cesarean Delivery

OBJECTIVE

To compare two methods of maternal warming during cesarean delivery under spinal anesthesia on maternal and newborn outcomes.

DESIGN

Randomized control trial.

SETTING

Two acute care hospitals in central Canada.

PATIENTS

62 women (32 intervention, 30 control).

INTERVENTIONS

Women received either a forced-air warming blanket (intervention) or usual care warmed cotton blankets (control).

MAIN OUTCOME MEASURES

For mothers: oral temperature, degree of shivering, thermal comfort, and pain scores. For newborns: rectal temperature at birth, 1- and 5-minute Apgar scores, and frequency of interventions for hypoglycemia within 3 hours of birth.

RESULTS

With the exception of perceived thermal comfort, women in the two groups were not significantly different in terms of oral temperature, incidence of shivering, and pain scores. Similarly, newborns in both groups were not significantly different in terms of any of the measured variables. Although newborn rectal temperature was within the normal range, mothers in both groups showed a significant decline in body temperature to the mild hypothermic range (control 36.7 +/- 0.4 degrees C to 35.9 +/- 0.5 degrees C, p < .001; intervention 36.8 +/- 0.4 degrees C to 36.1 +/- 0.4 degrees C, p < .001).

CONCLUSION

The usual treatment of supplying warmed cotton blankets remains the treatment of choice for this population.

Reflex activation of rat fusimotor neurons by body surface cooling, and its dependence on the medullary raphe

The nature of muscle efferent fibre activation during whole body cooling was investigated in urethane-anaesthetized rats. Multiunit efferent activity to the gastrocnemius muscle was detected when the trunk skin was cooled by a water-perfused jacket to below 36.0 +/- 0.7 degrees C. That efferent activity was not blocked by hexamethonium (50 mg kg(-1), i.v.) and was not associated with movement or electromyographic activity. Cold-induced efferent activity enhanced the discharge of afferent filaments from the isotonically stretched gastrocnemius muscle, demonstrating that it was fusimotor. Fusimotor neurons were activated by falls in trunk skin temperature, but that activity ceased when the skin was rewarmed, regardless of how low core temperature had fallen. While low core temperature alone was ineffective, a high core temperature could inhibit the fusimotor response to skin cooling. Fusimotor activation by skin cooling was often accompanied by desynchronization of the frontal electroencephalogram (EEG), but was not a simple consequence of cortical arousal, in that warming the scrotum desynchronized the EEG without activating fusimotor fibres. Inhibition of neurons in the rostral medullary raphé by microinjections of glycine (0.5 m, 120-180 nl) reduced the fusimotor response to skin cooling by 95 +/- 3%, but did not prevent the EEG response. These results are interpreted as showing a novel thermoregulatory reflex that is triggered by cold exposure. It may underlie the increased muscle tone that precedes overt shivering, and could also serve to amplify shivering. Like several other cold-defence responses, this reflex depends upon neurons in the rostral medullary raphé.

Fuel selection in shivering humans

Heat exchange has been thoroughly studied in cold-exposed humans, but the metabolic substrates used for thermogenesis have received less attention. This review deals with oxidative fuel selection in shivering humans. Lipids provide most of the heat during low-intensity shivering, whereas carbohydrates become dominant under more extreme cold conditions. The contribution from plasma glucose always remains minor, but muscle glycogen plays an important role during intense shivering. Whether the size of muscle glycogen stores influences endurance in the cold remains to be demonstrated. The fuel selection patterns of shivering and exercise are different, but the mechanisms underlying this difference have not been investigated. The simultaneous measurement of metabolic substrate oxidation and muscle fibre recruitment has allowed to characterize two different mechanisms of fuel selection in shivering humans: the recruitment of different pathways within the same fibres and of different fuel-specific fibres within the same muscles. This suggests that muscle fibre composition of each individual may affect survival. Future research promises to provide a combination of theoretical advances on fundamental principles of fuel selection and applied strategies to manipulate fibre composition (through training) or fuel metabolism (through diet) to prolong human survival in cold environments.

Forced-air warming and fluid warming minimize core hypothermia during abdominal surgery

OBJECTIVE

To evaluate the effect of intraoperative combined forced-air warming and fluid warming system on patient's core temperature, blood loss, transfusion demand, extubation time, and incidence of postoperative shivering.

METHODS

Forty patients with American Society of Anesthesiologists physical status I and II, aged 18-70 years, scheduled for elective abdominal surgery were randomly assigned to receive intraoperative warming from a forced-air blanket and fluid warming system or conventional cotton blanket, 20 in each group. The core temperature was recorded every 20 minutes during the operation, as well as the blood loss, blood transfusion, extubation time, and incidence of postoperative shivering.

RESULTS

The core temperature at the end of the surgery in the warming group was significantly different from that in the control group (36.4 +/- 0.4 degrees C vs. 35.3 +/- 0.5 degrees C, P < 0.001). Application of intraoperative warming significantly shortened the time between the end of the surgery and extubation (P < 0.01). Postoperative shivering occurred in 30% of the patients in the control group compared to no patient in the warming group (P < 0.01).

CONCLUSION

Active warming with air-forced blanket and fluid warming system provides sufficient heat to prevent hypothermia during abdominal surgery.

Physiology and clinical relevance of induced hypothermia

Experimental evidence and clinical experience suggest that mild hypothermia protects numerous tissues from damage during ischemic insult. However, the extent to which hypothermia becomes a valued therapeutic option will depend on the clinician's ability to rapidly reduce core body temperature and safely maintain hypothermia. To date, general anesthesia is the best way to block autonomic defenses during induction of mild-to-moderate hypothermia; unfortunately, general anesthesia is not an option in most patients likely to benefit from therapeutic hypothermia. Induction of hypothermia in awake humans is complicated by both the technical difficulties related to thermal manipulation and the remarkable efficacy of thermoregulatory defenses, especially vasoconstriction and shivering. The most effective thermal manipulation devices are generally invasive and, therefore, more prone to complications than surface methods. In an effort to inhibit thermoregulation in awake humans, several agents have been tested either alone or in combination with each other. For example, the combination of meperidine and buspirone has already been applied to facilitate induction of hypothermia in human trials. However, pharmacological induction of thermoregulatory tolerance to cold without excessive sedation, respiratory depression, or other serious toxicity remains a major focus of current therapeutic hypothermia research.