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.

Inhibition of shivering in hypothermic seals during diving

The mammalian response to hypothermia is increased metabolic heat production, usually by way of muscular activity, such as shivering. Seals, however, have been reported to respond to diving with hypothermia, which in other mammals under other circumstances would have elicited vigorous shivering. In the diving situation, shivering could be counterproductive, because it obviously would increase oxygen consumption and therefore reduce diving capacity. We have measured the electromyographic (EMG) activity of three different muscles and the rectal and brain temperature of hooded seals ( Cystophora cristata) while they were exposed to low ambient temperatures in a climatic chamber and while they performed a series of experimental dives in cold water. In air, the seals had a normal mammalian shivering response to cold. Muscles were recruited in a sequential manner until body temperature stopped dropping. Shivering was initiated when rectal temperature fell below 35.3 ± 0.6°C ( n = 6). In the hypothermic diving seal, however, the EMG activity in all of the muscles that had been shivering vigorously before submergence was much reduced, or stopped altogether, whereas it increased again upon emergence but was again reduced if diving was repeated. We conclude that shivering is inhibited during diving to allow a decrease in body temperature whereby oxygen consumption is decreased and diving capacity is extended.

Heated and humidified insufflation during laparoscopic gastric bypass surgery: effect on temperature, postoperative pain, and recovery outcomes

BACKGROUND

Controversy exists regarding the efficacy of heated and humidified intraperitoneal gases in maintaining core body temperature. We performed a sham-controlled study to test the hypothesis that active warming and humidification of the insufflation gas reduces intraoperative heat loss and improves recovery outcomes.

PATIENTS AND METHODS

Fifty morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass procedures using a standardized anesthetic technique were randomly assigned to either a control (sham) group receiving room temperature insufflation gases with an inactive Insuflow (Lexion Medical, St. Paul, MN) device, or an active (Insuflow) group receiving warmed and humidified intraperitoneal gases. Esophageal and/or tympanic membrane temperature was measured perioperatively. Postoperative pain was assessed at 15 minute intervals using an 11-point verbal rating scale, with 0 = none to 10 = maximal. In addition, postoperative opioid requirements, incidence of nausea and vomiting, as well as the quality of recovery, were recorded.

RESULTS

Use of the active Insuflow device was associated with significantly higher mean +/- standard deviation (SD) intraoperative core body temperatures (35.5 +/- 0.5 vs. 35.0 +/- 0.4 degrees C). Postoperative shivering (0 vs. 19%) and the requirement for morphine in the postanesthesia care unit (5 +/- 4 vs. 10 +/- 5 mg) were both significantly lower in the Insuflow vs. control groups. Patients in the Insuflow group also reported a higher quality of recovery 48 hours after surgery (15 vs. 13, P < 0.05).

CONCLUSION

The Insuflow device modestly reduced shivering and heat loss, as well as the need for opioid analgesics in the early postoperative period. However, it failed to improve laparoscopic visualization due to fogging, and provided improvement in the quality of recovery only on postoperative day 2.

Partitioning oxidative fuels during cold exposure in humans: muscle glycogen becomes dominant as shivering intensifies

The effects of changes in shivering intensity on the relative contributions of plasma glucose, muscle glycogen, lipids and proteins to total heat production are unclear in humans. The goals of this study were: (1) to determine whether plasma glucose starts playing a more prominent role as shivering intensifies, (2) to quantify overall changes in fuel use in relation to the severity of cold exposure, and (3) to establish whether the fuel selection pattern of shivering is different from the classic fuel selection pattern of exercise. Using a combination of indirect calorimetry and stable isotope methodology, fuel metabolism was monitored in non-acclimatized adult men exposed for 90 mins to 10 degrees C (low-intensity shivering (L)) or 5 degrees C (moderate-intensity shivering (M)). Results show that plasma glucose oxidation is strongly stimulated by moderate shivering (+122% from L to M), but the relative contribution of this pathway to total heat generation always remains minor (< 15% of total heat production). Instead, muscle glycogen is responsible for most of the increase in heat production between L and M. By itself, the increase in CHO oxidation is responsible for the 100 W increase in metabolic rate observed between L and M, because rates of lipid and protein oxidation remain constant. This high reliance on CHO is not compatible with the well known fuel selection pattern of exercise, when considering the relatively low metabolic rates elicited by shivering (approximately 30% for M). We conclude that shivering and exercise of similar energy requirements appear to be supported by different fuel mixtures. Investigating the physiological mechanisms underlying why a muscle producing only heat (shivering), or significant movement (exercise), shows a different pattern of fuel selection at the same power output strikes us as a fascinating area for future research.

Nefopam or clonidine in the pharmacologic prevention of shivering in patients undergoing conscious sedation for interventional neuroradiology

The aim of this randomised, double-blind study was to investigate the usefulness of intravenous nefopam, clonidine or placebo in preventing shivering in patients undergoing conscious sedation for interventional neuroradiological procedures. A total of 101 patients were prospectively enrolled and assigned to one of three groups to receive nefopam, clonidine or placebo. The overall incidence of intra-operative shivering was significantly lower in patients treated with nefopam than in those treated with clonidine or placebo (2/32 (6%) vs. 11/38 (29%), p < 0.02; 2/32 (6%) vs. 24/31 (77%), p < 0.0001, respectively). The number of patients who required ephedrine infusions to maintain a mean arterial pressure of 100 mm Hg was higher in the clonidine group than in the nefopam and placebo groups (18/38 (47%) vs. 5/32 (17%), p < 0.05; 18/38 (47%) vs. 6/31 (19%), p < 0.05, respectively). We found that both nefopam and clonidine significantly lowered the rate and severity of shivering during interventional neuroradiological procedures. Fewer patients in the nefopam group than in the other two groups required vasoactive drugs.

Shivering in acutely ill vulnerable populations

The hazards of thermoregulatory shivering in the critically ill are often overlooked by caregivers. Shivering may accompany heat loss from bathing, dressing, transport, and many therapeutic activities. Febrile shivering is common during chills of fever, blood product transfusions, administration of antigenic drugs, and chemotherapy. Many patients are at risk for shivering and its negative consequences that increase oxygen expenditure and cardiorespiratory effort. Learning how underlying thermoregulatory mechanisms are involved in shivering clarifies how temperature gradients and environmental stimuli induce the shivering response. Knowledge of the anatomical progression of shivering equips the nurse to recognize or prevent this energy-consuming response. This article discusses measures to prevent shivering as well as evidence-based interventions to manage shivering during fever, aggressive cooling, and postoperative recovery. Detailed information is presented on assessment and documentation of the extent and severity of shivering.

Body temperature, behavior, and plasma cortisol changes induced by chronic infusion of Staphylococcus aureus in goats

Most experimentally induced fevers are acute, usually lasting ∼6–12 h, and thus do not mimic chronic natural fevers, which can extend over several days or more. To produce a model of chronic natural fever, we infused eight goats ( Capra hircus) intravenously with 2 ml of 2 × 1011 cell walls of Staphylococcus aureus ( S. aureus) for 6 days using osmotic infusion pumps (10 μl/h) while measuring changes in body temperature, behavior, and plasma cortisol concentration. Seven control animals were infused with sterile saline. Abdominal temperature-sensitive data loggers and osmotic infusion pumps were implanted under halothane anesthesia. To compare our new model with existing models of experimental fever, we also administered 2-ml bolus intravenous injections of 2 × 1011 S. aureus cell walls, 0.1 μg/kg lipopolysaccharide ( Escherichia coli, serotype 0111:B4), and sterile saline in random order to six other goats. Bolus injection of lipopolysaccharide and S. aureus induced typical acute phase responses, characterized by fevers lasting ∼6 h, sickness behavior, and increased plasma cortisol concentration. Infusion of S. aureus evoked prolonged fevers, which lasted for ∼3 days, starting on day 4 of infusion (ANOVA, P < 0.05), and did not disrupt the normal circadian rhythm of body temperature. However, pyrogen infusion did not cause plasma cortisol concentration to rise (ANOVA, P > 0.05) or the expression of sickness behavior. In conclusion, infusion of S. aureus produced a fever response resembling that of sustained natural fevers but did not elicit the cortisol and behavioral responses that often are described clinically and during short-term experimental fevers.

[The effect of intraoperative warming on patient core temperature]

OBJECTIVE

To investigate the influence of using fluid warming and forced-air warming system on patient core temperature, blood loss, blood transfusion, extubation time, and postoperative shivering.

METHODS

Forty ASA (American Society of Anesthesiologists' Physical Status) I-II patients, aged 21-69 years, scheduled for elective abdominal surgery under general anesthesia, were enrolled in the study. The patients were premedicated with intramuscular dolantin 50 mg and atropine 0.5 mg. Anesthesia was induced with midazolam 1 mg, fentanyl 50-100 microg and propofol 1.5-2.0 mg/kg. Tracheal intubation was facilitated with vecuronium 1mg and succinylcholine 1.5-2.0 mg/kg. The patients were mechanically ventilated and anesthesia was maintained with isoflurane 1.5-2.0%, 50% N2O in oxygen and intermittent iv boluses of fentanyl (total dose 5-6 microg/kg). Vecuronium was used for muscle relaxation during maintenance of anesthesia. The patients were randomly divided into 2 groups: control group (n = 20) and warming group (n = 20). In both groups, the patients were covered with surgery blanket. In the warming group, patients were additionally warmed with fluid warming device and forced-air warming system during the operation. The core temperature was recorded every 20 minutes during the operation, as well as the blood loss, blood transfusion, extubation time and postoperative shivering.

RESULTS

The core temperature at the end of the surgery was (36.4 +/- 0.4) degrees C in the warming group and (35.3 +/- 0.5) degrees C in the control group. The difference was statistically significant (t = 7.547, P < 0.001). There was no significant difference of blood loss and blood transfusion between two groups. The extubation time was significantly shorter in the warming group [(18 +/- 6) vs (26 +/- 10) min, t = -3.364, P = 0.002]. 6 patients shivered postoperatively in the control group and none in the warming group (chi2 = 7.059, P = 0.008).

CONCLUSION

Fluid warming system and forced-air warming system can effectively maintain normothermia during the surgery and then help to reduce the extubation time and postoperative shivering.

Lower Limb Wrapping Prevents Hypotension, but Not Hypothermia or Shivering, After the Introduction of Epidural Anesthesia for Cesarean Delivery

The decrease of arterial blood pressure and body temperature after epidural or spinal anesthesia is thought to be the result of sympathetic block, which could cause pooling and redistribution of blood into the lower extremities. Studies have demonstrated that leg wrapping with elastic bandages may reduce the incidence of hypotension after spinal anesthesia. We tried to extend these previous observations to epidural anesthesia by testing the hypothesis that leg wrapping with elastic bandages should decrease the incidence of hypotension in patients receiving epidural anesthesia. Moreover, we evaluated the effect of this maneuver as regards hypothermia and shivering. Sixty parturients were randomly allocated to receive either leg wrapping with tight elastic bandages (leg-wrapped group) or not (control group) before anesthesia. Sublingual temperature was observed at five periods: baseline, immediately after epidural anesthesia, abdominal skin disinfection, skin incision, and delivery. Hypotension and shivering during the observation periods were also recorded. The incidence of hypotension was significantly less frequent (P = 0.03) in the leg-wrapped group (23%) compared with the control group (50%). Shivering incidences were similar in both groups (70% versus 70%). Sublingual temperature decreased significantly (P < 0.001) throughout the procedure in each group. However, no differences were found between the two groups at each designated observation, even if compared by the magnitude of temperature decrease. We conclude that although leg wrapping with elastic bandages prevents maternal hypotension after epidural anesthesia, it does not reduce the incidence or magnitude of hypothermia or prevent shivering.

Efficacy of postoperative rewarming after cardiac surgery

OBJECTIVE

To compare the efficacy of forced-air warmers and radiant heaters on rewarming after cardiac surgery in a prospective randomized study.

METHODS

Fifty male patients who had undergone coronary artery bypass graft surgery were studied. The control group (Gr. C, n=10) was nursed under a standard hospital blanket. Two groups were treated with forced-air warmers: WarmTouch 5700 (Gr. WT, n=10) and Bair Hugger 500 (Gr. BH, n=10). Two other groups were treated by radiant heaters: the Aragona Thermal Ceilings CTC X radiant heater (Gr. TC, n=10) and a self assembled radiant heater of 4 Hydrosun 500 infrared lamps (Gr. HY, n=10). Changes of oesophageal temperature, mean skin temperature, mean body temperature and relative heat balance were calculated from oesophageal temperature, 4 skin temperatures and oxygen consumption (VO(2)).

RESULTS

All actively treated groups with exception of the TC group showed significantly faster oesophageal warming than the control group. The mean body temperature increased 1.1 (0.7-1.7) degrees Ch(-1) in Gr. WT, 1.3 (0.7-1.5) degrees Ch(-1) in Gr. BH, 0.8 (0.5-1.4) degrees Ch(-1) in Gr. TC and 0.7 (0.4-1.0) degrees Ch(-1) in Gr. HY compared to Gr. C with 0.4 (0.2-0.7) degrees Ch(-1). The mean VO(2) and the maxima of the VO(2) during the study period did not differ significantly between the groups.

CONCLUSION

In the current setting active warming, forced-air warming more than radiant warming, increased speed of rewarming two- to threefold in comparison to insulation with a blanket.

Human physiological responses to cold exposure

Thermal energy is transferred within and between bodies via several avenues, but for most unprotected human cold exposures, particularly during immersion, convective heat loss dominates. Lower tissue temperatures stimulate thermoreceptors, and the resultant afferent flow elicits autonomic homoeostatic responses (thermogenesis and vasoconstriction) that regulate body temperature within a narrow range. The most powerful effector responses occur when both superficial and deep thermoreceptors are cooled simultaneously, but thermoeffector activation can also occur as a result of peripheral cooling alone. The responses to cold, and the hazards associated with cold exposure, are moderated by factors which influence heat production and heat loss, including the severity and duration of cold stimuli, accompanying exercise, the magnitude of the metabolic response, and individual characteristics such as body composition, age, and gender. Cold stress can quickly overwhelm human thermoregulation with consequences ranging from impaired performance to death. This review provides a comprehensive overview of the human physiological responses to acute cold exposure.

Fuel selection during intense shivering in humans: EMG pattern reflects carbohydrate oxidation

The thermogenic response of humans depends critically on the coordination of muscle fibre recruitment and oxidative fuel metabolism. The primary goal of this study was to determine whether the electromyographic (EMG) pattern of muscle recruitment could provide metabolic information on oxidative fuel selection during high-intensity shivering. EMG activity (of 8 large muscles) and fuel metabolism were monitored simultaneously in non-acclimatized adult men during high-intensity shivering. Even though acute cold exposure elicited similar changes in metabolic rate among subjects, lipid and carbohydrate use was very different. Depending on the subject, the cold-induced increase in carbohydrate (CHO) oxidation ranged between 2- and 8-fold, with CHO accounting for 33-78% of total heat production, and lipids for 14-60%. This high variability in fuel selection was primarily explained by differences in 'burst shivering' rate, indicating that the recruitment of type II fibres plays a key role in orchestrating fuel selection. This study is the first to show that the pattern of muscle recruitment can provide quantitative information on energy metabolism. Future work should focus on the study of shivering bursts that may provide essential clues on what limits human survival in the cold.

Effect of postoperative skin-surface warming on oxygen consumption and the shivering threshold

Cutaneous warming is reportedly an effective treatment for shivering during epidural and after general anaesthesia. We quantified the efficacy of cutaneous warming as a treatment for shivering. Unwarmed surgical patients (final intra-operative core temperatures approximately 35 degrees C) were randomly assigned to be covered with a blanket (n = 9) or full-body forced-air cover (n = 9). Shivering was evaluated clinically and by oxygen consumption. Forced-air heating increased mean-skin temperature (mean (SD) 35.7 degrees C (0.4) vs. 33.2 degrees C (0.8); p < 0.0001) and lowered core temperature at the shivering threshold (35.7 degrees C (0.2) vs. 36.4 degrees C(0.2); p < 0.0001). Active warming improved thermal comfort and significantly reduced oxygen consumption from 9.7 (4.4) ml x min(-1) x kg(-1) to 5.6 (1.9) ml x min(-1) x kg(-1) (p = 0.038). However, the duration of shivering was similar in the unwarmed (37 min (11)) and active warming (36 min (10)) groups. Core temperature contributed about four times as much as skin temperature to control of shivering. Cutaneous warming improved thermal comfort and reduced metabolic stress in postoperative patients, but did not quickly obliterate shivering.

Effects of carbohydrate availability on sustained shivering II. Relating muscle recruitment to fuel selection

The purpose of this study was to quantify how shivering activity would be affected by large changes in fuel metabolism (see Haman F, Peronnet F, Kenny GP, Doucet E, Massicotte D, Lavoie C, and Weber J-M, J Appl Physiol 96: 000-000, 2004). Adult men were exposed to 10 degrees C for 2 h after a low-carbohydrate diet and exercise (Lo) and after high-carbohydrate diet without exercise (Hi). Using simultaneous metabolic and electromyographic (EMG) measurements, we quantified the effects of changes in fuel selection on the shivering activity of eight large muscles representing >90% of total shivering muscle mass. Contrary to expectation, drastic changes in fuel metabolism [carbohydrates 28 vs. 65% of total heat production (Hprod), lipids 53 vs. 23% Hprod, and proteins 19 vs. 12% Hprod for Lo and Hi, respectively] are achieved without altering the EMG signature of shivering muscles. Results show that total shivering activity and the specific contribution of each muscle to total shivering activity are not affected by large changes in fuel selection. In addition, we found that changes in burst shivering rate ( approximately 4 bursts/min), relative contribution of burst activity to total shivering ( approximately 10% of total shivering activity), and burst shivering intensity ( approximately 12% of maximal voluntary contraction) are the same between Lo and Hi. Spectral analysis of EMG signals also reveals that mean frequencies of the power spectrum remained the same under all conditions (whole body average of 78 +/- 5 Hz for Lo and 83 +/- 7 Hz for Hi). During low-intensity shivering, humans are therefore able to sustain the same thermogenic rate by oxidizing widely different fuel mixtures within the same muscle fibers.

Effects of carbohydrate availability on sustained shivering I. Oxidation of plasma glucose, muscle glycogen, and proteins

Carbohydrates (CHO) can play an important thermogenic role during shivering, but the effect of their availability on the use of other oxidative fuels is unclear. Using indirect calorimetry and tracer methods ([U-13C]glucose ingestion), we have determined the specific contributions of plasma glucose, muscle glycogen, proteins, and lipids to total heat production (Hprod) in men exposed to cold for 2-h (liquid-conditioned suit perfused with 10 degrees C water). Measurements were made after low-CHO diet and exercise (Lo) and high-CHO diet without exercise (Hi). The size of CHO reserves had no effect on Hprod but a major impact on fuel selection before and during shivering. In the cold, a complete shift from lipid oxidation for Lo (53, 28, and 19% Hprod for lipids, CHO, and proteins, respectively) to CHO-based metabolism for Hi (23, 65, and 12% Hprod for lipids, CHO, and proteins, respectively) was observed. Plasma glucose oxidation remains a minor fuel under all conditions (<13% Hprod), falling to 7% Hprod for Lo. Therefore, adjusting plasma glucose oxidation to compensate for changes in muscle glycogen oxidation is not a strategy used for maintaining heat production. Instead, proteins and lipids share responsibility for this compensation. We conclude that humans can show remarkable flexibility in oxidative fuel selection to ensure that heat production is not compromised during sustained cold exposure.

[Fever-shivers reaction and standard platelet concentrates transfusion: a prospective study]

Fever-shivers reaction (FSR) is the most frequent transfusion immediate incident related to platelet transfusions. The aim of our prospective study was to assess the frequency of the different immediate incidents, especially the frequency and the causes of the FSR, observed during the transfusion of standard platelet concentrates (SPC). For each FSR, analysis of causes included: a bacterial culture of the implicated SPC, a blood culture and HLA antibody screening (lymphocytotoxicity assay) among the patients. In the study period, 34 patients were followed during 74 transfusions. Ten immediate incidents were noted; FSR: N = 8, erythema-urticaria: N = 1 and nausea-vomit: N = 1. The FSR was observed in 6 patients who received 56 SPC. Analysis of causes of this reaction revealed that: HLA antibodies were present in one patient; bacterial contamination was not found neither among the patients nor in the implicated SPC, and the risk of the FSR occurrence rose with increased storage time of the SPC transfused. Indeed, a significant difference was noted between the mean age of the SPC implicated in the FSR and the mean age of those not implicated (P = 0,0028). In conclusion, the FSR is a frequent incident observed during SPC transfusions. In the majority of cases, the cause of this reaction was not identified. Further studies will be necessary to better understand the physiological mechanisms of the FSR.

The Hemodynamic and Metabolic Effects of Shivering During Acute Normovolemic Hemodilution

To assess the hemodynamic and metabolic effects of shivering during extreme normovolemic hemodilution, we anesthetized 16 pigs with fentanyl-midazolam-pancuronium. Mild hypothermia (36.5 degrees +/- 0.1 degrees C) was induced by surface cooling, and the animals were randomized to either a control group (hemoglobin 118 +/- 3 g/L) or a hemodilution group (hemoglobin 52 +/- 2 g/L). In the latter group, blood was replaced with an isotonic Ringer's acetate/dextran 70 solution. Shivering was allowed to occur by a controlled decrease in the infusion rate of pancuronium. Shivering increased oxygen consumption (VO(2)) in both groups (P < 0.001). Initially, this was predominantly compensated for by an increased oxygen extraction ratio (ER), but when VO(2) was 2.3 +/- 0.2 times baseline, critical levels of mixed venous oxygenation (SVO(2) = 18% +/- 2%; PVO(2) = 22.5 +/- 1.5 mm Hg) and ER (82% +/- 3%) were recorded in anemic animals. Control animals did not reach critical levels until VO(2) was maximal (3.7 +/- 0.3 times baseline). Maximal attained VO(2) was less (2.9 +/- 0.1 times baseline) in the anemic animals (P = 0.01), and at this stage two of these pigs had myocardial lactate production, one of which died in ventricular fibrillation. Coronary perfusion pressure was significantly less (P < 0.001) in the anemic animals. We conclude that in this experimental model, maximal shivering as measured by VO(2) was limited in hemodiluted animals, and left ventricular oxygen balance was marginal, as evidenced by a decreased lactate uptake and extraction.

IMPLICATIONS

The effect of acute increases in oxygen consumption (shivering) on severely anemic individuals has not been evaluated. In this experimental model, left ventricular oxygen balance was marginal, as evidenced by decreased lactate extraction.

Postoperative shivering in children: a review on pharmacologic prevention and treatment

Postoperative shivering consists of muscular tremor and rigidity. It is often associated with body heat loss, although hypothermia alone does not fully explain the occurrence of shivering. Shivering is self-limiting, never becomes chronic, and is rarely associated with major morbidity. However, it affects the comfort of the patients, and may sometimes lead to more serious complications. The efficacy of a great variety of pharmacologic interventions to prevent shivering and to treat established symptoms has been tested in randomized controlled trials. These can be gathered systematically; recommendations on prevention and treatment can then be based on the strongest evidence. Unfortunately all these trials have been performed in adults. Thus, recommendations for the control of postoperative shivering in children have to be extrapolated from adult data. In adults, a systematic review strongly suggests that simple measurements are efficacious for both prevention and treatment. For prevention, extrapolation of these adult data indicates that three children have to receive intravenous clonidine 1.5 micro g/kg during anesthesia for one not to shiver, when they would have done so had they not received clonidine. For this degree of efficacy, the expected incidence of shivering (baseline risk) has to be high (approximately 50%). For treatment, extrapolation from adult data indicates that less than two children need to receive intravenous meperidine (pethidine) 0.35 mg/kg, or clonidine 1.5 micro g/kg for one to stop shivering five minutes after drug administration, when they would not have done so had they not received one of these drugs. Since the treatment of established shivering is efficacious, simple, inexpensive, and relatively safe, and since prevention is only efficacious if the baseline risk is very high, we recommend the 'wait and see' strategy.

[Stimulation of thermoregulatory and respiratory functions with the help of EDTA and EGTA during deep hypothermia in rats]

Influence of EDTA (C10H14N2Na2O8.2H2O) and EGTA (C14H24N2O10) on physiological functions homoiothermic organisms at deep hypothermia, was studied. White rats during cooling were in special sections without rigid fixing of head and limbs. In reply to intravenous introduction of EDTA and EGTA solutions, similar answers of the organisms were observed: raised breathing frequency and amplitude, intensity of electrical activity of muscles; these signs of activation of physiological functions lasted 8-10 minutes. Besides, of the 20th-30th minute after introduction of the second dose of preparations (at rectal temperature 17.1 +/- 0.5 degrees C), the secondary activation respiratory and thermoregulatory functions were registered. The termination of the cold shivering in experiments with introduction of EDTA and EGTA solutions occurred at lower temperatures in rectum and in a brain (16.7-17.3 degrees and 17.8-18.2 degrees C, resp.) than in control experiments (18.7 +/- 0.6 degrees C and 20.2 +/- 1.5 degrees C). The authors suppose that the activation of the thermoregulatory and respiratory functions is caused by a decrease in concentration of ions Ca2+ in the blood plasma.

Force control of isometric elbow flexion with visual feedback in cold with and without shivering

BACKGROUND

Exposure to cold impairs manual performance through effects on muscle tissue and control mechanisms. The purpose of this study was to assess the influence of increased muscle tone and shivering on ability to maintain required force during isometric flexion over a wide range of effort levels.

METHODS

Lightly clad male subjects (n = 6) were exposed to thermoneutral air (TN, 27 degrees C) for 30 min, or to cold air (CA, 10 degrees C) for 30 min followed by a cold drink (1 L, 8 degrees C) to cause vigorous shivering (SH). At the end of each condition, subjects performed isometric elbow flexion at 10, 20, 40, and 80% of individual maximal voluntary contraction (MVC) for 10 s each, using digital visual feedback to control the force. We analyzed mean force output (F), the coefficient of force variation (FCv), information transmission (F/SD), and the coefficient of force auto-correlation (Ra), and the averaged electromyogram (aEMG) from elbow flexors, elbow extensor, and pectoral girdle muscles.

RESULTS

Compared with TN, CA with increased muscle tone raised the aEMG by 5-30% but did not impair any of the force characteristics. In SH, F was not affected, while FCv and Ra were significantly increased at 10% MVC, while aEMG increased by 30-400% depending on the specific muscle and MVC level.

CONCLUSION

Neither thermoregulatory muscle tone nor shivering influenced the control of force output during isometric elbow flexion, except that at the lowest MVC (10%) the force output was more variable during shivering.

Neither arm nor face warming reduces the shivering threshold in unanesthetized humans

BACKGROUND AND PURPOSE

Hand warming and face warming, combined with inhalation of heated air, are reported to suppress shivering. However, hand or face temperature contributes only a few percent to control of shivering. Thus, it seems unlikely that manipulating hand or facial skin temperature alone would be sufficient to permit induction of therapeutic hypothermia. We tested the hypothesis that focal arm (forearm and hand) warming or lower facial warming, combined with inhalation of heated and humidified gas, only minimally reduces the shivering threshold (triggering core temperature).

METHODS

We studied 8 healthy male volunteers (18 to 40 years of age) on 3 days: (1) control (no warming), (2) arm warming with forced air at approximately 43 degrees C, and (3) face warming with 21 L/min of air at approximately 42 degrees C at a relative humidity of 100%. Fluid at approximately 4 degrees C was infused via a central venous catheter to decrease tympanic membrane temperature 1 degrees C/h to 2 degrees C/h; mean skin temperature was maintained at 31 degrees C. A sustained increase in oxygen consumption quantified the shivering threshold.

RESULTS

Shivering thresholds did not differ significantly between the control (36.7+/-0.1 degrees C), arm-warming (36.5+/-0.3 degrees C), or face-warming (36.5+/-0.3 degrees C; analysis of variance, P=0.34) day. The study was powered to have a 95% probability of detecting a difference of 0.5+/-0.5 degrees C (mean+/-SD) between control and either of the 2 treatments at alpha=0.05.

CONCLUSIONS

Focal arm or face warming did not substantially reduce the shivering threshold in unanesthetized volunteers. It thus seems unlikely that these nonpharmacological modalities will substantially facilitate induction of therapeutic hypothermia.