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Recio-Pérez J, Miró Murillo M, Martin Mesa M, Silva García J, Santonocito C, Sanfilippo F, Asúnsolo A. Effect of Prewarming on Perioperative Hypothermia in Patients Undergoing Loco-Regional or General Anesthesia: A Randomized Clinical Trial. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2082. [PMID: 38138185 PMCID: PMC10744774 DOI: 10.3390/medicina59122082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/10/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: Redistribution hypothermia occurs during anesthesia despite active intraoperative warming. Prewarming increases the heat absorption by peripheral tissue, reducing the central to peripheral heat gradient. Therefore, the addition of prewarming may offer a greater preservation of intraoperative normothermia as compared to intraoperative warming only. Materials and Methods: A single-center clinical trial of adults scheduled for non-cardiac surgery. Patients were randomized to receive or not a prewarming period (at least 10 min) with convective air devices. Intraoperative temperature management was identical in both groups and performed according to a local protocol. The primary endpoint was the incidence, the magnitude and the duration of hypothermia (according to surgical time) between anesthetic induction and arrival at the recovery room. Secondary outcomes were core temperature on arrival in operating room, surgical site infections, blood losses, transfusions, patient discomfort (i.e., shivering), reintervention and hospital stay. Results: In total, 197 patients were analyzed: 104 in the control group and 93 in the prewarming group. Core temperature during the intra-operative period was similar between groups (p = 0.45). Median prewarming lasted 27 (17-38) min. Regarding hypothermia, we found no differences in incidence (controls: 33.7%, prewarming: 39.8%; p = 0.37), duration (controls: 41.6% (17.8-78.1), prewarming: 45.2% (20.6-71.1); p = 0.83) and magnitude (controls: 0.19 °C · h-1 (0.09-0.54), prewarming: 0.20 °C · h-1 (0.05-0.70); p = 0.91). Preoperative thermal discomfort was more frequent in the prewarming group (15.1% vs. 0%; p < 0.01). The interruption of intraoperative warming was more common in the prewarming group (16.1% vs. 6.7%; p = 0.03), but no differences were seen in other secondary endpoints. Conclusions: A preoperative prewarming period does not reduce the incidence, duration and magnitude of intraoperative hypothermia. These results should be interpreted considering a strict protocol for perioperative temperature management and the low incidence of hypothermia in controls.
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Affiliation(s)
- Jesus Recio-Pérez
- Department of Anesthesia, Torrejon University Hospital, 28850 Torrejón de Ardoz, Spain; (M.M.M.)
| | - Miguel Miró Murillo
- Department of Anesthesia, Torrejon University Hospital, 28850 Torrejón de Ardoz, Spain; (M.M.M.)
| | - Marta Martin Mesa
- Department of Anesthesia, Torrejon University Hospital, 28850 Torrejón de Ardoz, Spain; (M.M.M.)
| | | | - Cristina Santonocito
- Department of Anesthesia and Intensive Care, University Hospital “Policlinico-San Marco”, 95124 Catania, Italy;
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, University Hospital “Policlinico-San Marco”, 95124 Catania, Italy;
- Department of Surgery and Medical-Surgical Specialties, University of Catania, 95124 Catania, Italy
| | - Angel Asúnsolo
- Department of Public Health, Alcala University, 28801 Alcala de Henares, Spain
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Skok K, Duh M, Stožer A, Markota A, Gosak M. Thermoregulation: A journey from physiology to computational models and the intensive care unit. WILEY INTERDISCIPLINARY REVIEWS. SYSTEMS BIOLOGY AND MEDICINE 2020; 13:e1513. [PMID: 33251759 DOI: 10.1002/wsbm.1513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/24/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
Abstract
Thermoregulation plays a vital role in homeostasis. Many species of animals as well as humans have evolved various physiological mechanisms for body temperature control, which are characteristically flexible and enable a fine-tuned spatial and temporal regulation of body temperature in different environmental conditions and circumstances. Human beings normally maintain a core body temperature at around 37°C, and maintenance of this relatively high temperature is critical for survival. Therefore, principles of thermoregulatory control have also important clinical implications. Infections can cause the body temperature to rise internally and several diseases can cause a dysfunction of thermoregulatory mechanisms. Moreover, the utilization of thermotherapies in treating various diseases has been known for thousands of years with a recent resurgence of interest. An increasing amount of research suggests that targeted temperature management is of paramount importance to patient outcomes in certain clinical scenarios. We provide a concise summary of the basic concepts of thermoregulation. Emphasis is given to the principles of thermoregulation in humans in basic pathological states and to targeted temperature management strategies in the clinical environment, with special attention on therapeutic hypothermia in postcardiac arrest patients. Finally, the discussion is focused on the potential offered by computational thermophysiological models for predicting thermal responses of patients in various clinical circumstances, for proposing new perspectives in the design of novel thermal therapies, and to optimize targeted temperature management strategies. This article is categorized under: Cardiovascular Diseases > Cardiovascular Diseases>Computational Models Cardiovascular Diseases > Cardiovascular Diseases>Environmental Factors Cardiovascular Diseases > Cardiovascular Diseases>Biomedical Engineering.
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Affiliation(s)
- Kristijan Skok
- Department of Pathology, General Hospital Graz II, Location West, Graz, Austria
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Maja Duh
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koros̆ka cesta, Maribor, Slovenia
| | - Andraž Stožer
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Andrej Markota
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Medical Intensive Care Unit, University Medical Centre Maribor, Maribor, Slovenia
| | - Marko Gosak
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koros̆ka cesta, Maribor, Slovenia
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Lenhardt R. Body temperature regulation and anesthesia. HANDBOOK OF CLINICAL NEUROLOGY 2018; 157:635-644. [DOI: 10.1016/b978-0-444-64074-1.00037-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
Core body temperature is normally tightly regulated to within a few tenths of a degree. The major thermoregulatory defences in humans are sweating, arteriovenous shunt vasoconstriction, and shivering. The core temperature triggering each response defines its activation threshold. General anaesthetics greatly impair thermoregulation, synchronously reducing the thresholds for vasoconstriction and shivering. Neuraxial anaesthesia also impairs central thermoregulatory control, and prevents vasoconstriction and shivering in blocked areas. Consequently, unwarmed anaesthetised patients become hypothermic, typically by 1-2°C. Hypothermia results initially from an internal redistribution of body heat from the core to the periphery, followed by heat loss exceeding metabolic heat production. Complications of perioperative hypothermia include coagulopathy and increased transfusion requirement, surgical site infection, delayed drug metabolism, prolonged recovery, shivering, and thermal discomfort. Body temperature can be reliably measured in the oesophagus, nasopharynx, mouth, and bladder. The standard-of-care is to monitor core temperature and to maintain normothermia during general and neuraxial anaesthesia.
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Affiliation(s)
- Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
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5
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Sessler DI. Opioids and postoperative shivering. J Clin Anesth 2016; 31:42-3. [PMID: 27185675 DOI: 10.1016/j.jclinane.2015.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/11/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH 44195, USA.
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Abstract
Modeling for cold stress has generated a rich history of innovation, has exerted a catalytic influence on cold physiology research, and continues to impact human activity in cold environments. This overview begins with a brief summation of cold thermoregulatory model development followed by key principles that will continue to guide current and future model development. Different representations of the human body are discussed relative to the level of detail and prediction accuracy required. In addition to predictions of shivering and vasomotor responses to cold exposure, algorithms are presented for thermoregulatory mechanisms. Various avenues of heat exchange between the human body and a cold environment are reviewed. Applications of cold thermoregulatory modeling range from investigative interpretation of physiological observations to forecasting skin freezing times and hypothermia survival times. While these advances have been remarkable, the future of cold stress modeling is still faced with significant challenges that are summarized at the end of this overview.
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Affiliation(s)
- Xiaojiang Xu
- Biophysics and Biomedical Modeling Division, U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts
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Zhumadilov A, Gilman CP, Viderman D. Management of super-refractory status epilepticus with isoflurane and hypothermia. Front Neurol 2015; 5:286. [PMID: 25674075 PMCID: PMC4309114 DOI: 10.3389/fneur.2014.00286] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/15/2014] [Indexed: 11/13/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is defined as status epilepticus that continues 24 h or more after the onset of anesthesia, and includes those cases in which epilepsy is recurrent upon treatment reduction. We describe the presentation and successful management of a male patient with SRSE using the inhaled anesthetic isoflurane, and mild hypothermia (HT). The potential utility of combined HT and volatile anesthesia is discussed.
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Affiliation(s)
- Agzam Zhumadilov
- Republican Research Center for Emergency Care, Astana, Kazakhstan
| | - Charles P. Gilman
- School of Science and Technology, Nazarbayev University, Astana, Kazakhstan
| | - Dmitriy Viderman
- Republican Research Center for Emergency Care, Astana, Kazakhstan
- School of Medicine, Nazarbayev University, Astana, Kazakhstan
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Hernandez M, Cutter TW, Apfelbaum JL. Hypothermia and hyperthermia in the ambulatory surgical patient. Clin Plast Surg 2014; 40:429-38. [PMID: 23830751 DOI: 10.1016/j.cps.2013.04.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Homeotherms, including humans, are able to maintain a relatively constant temperature despite variations in their thermal environment. We normally maintain a narrow thermoregulatory threshold range of approximately 0.2°C, and little change in core temperature is required to trigger compensatory mechanisms to either cool or warm our core temperature back to normothermia. This article focuses on the mechanisms and consequences of hypothermia and hyperthermia in the surgical patient and reviews techniques to prevent and treat these conditions.
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Affiliation(s)
- Michael Hernandez
- Department of Anesthesia and Critical Care, The University of Chicago Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
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9
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Volatile Anesthetic Sedation During Therapeutic Hypothermia After Cardiac Arrest in the ICU. Crit Care Med 2014; 42:494-5. [DOI: 10.1097/01.ccm.0000435689.93091.d0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Taniguchi Y, Lenhardt R, Sessler DI, Kurz A. The effect of altering skin-surface cooling speeds on vasoconstriction and shivering thresholds. Anesth Analg 2011; 113:540-4. [PMID: 21778332 DOI: 10.1213/ane.0b013e3182273b19] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Both core and skin temperatures contribute to steady-state thermoregulatory control. Dynamic thermoregulatory responses trigger aggressive defenses against rapid thermal perturbations. These responses potentially complicate interpretation of thermoregulatory studies and could slow induction of therapeutic hypothermia. We thus tested the hypothesis that rapid external skin-cooling triggers vasoconstriction and shivering at higher mean skin temperatures than slow or moderate rates of skin cooling. METHODS Eleven healthy volunteers were cooled at 3 skin-cooling rates using forced air or/and conductive cooling in random order. One day volunteers received slow (≈2°C/h) skin cooling, and on another day, they received both medium (≈4°C/h) and fast (≈6°C/h) skin cooling. An endovascular heat-exchanging catheter maintained core temperature. Fingertip blood flow ≤0.25 mL/min defined onset of vasoconstriction; sustained ≥25% increase in oxygen consumption defined onset of shivering. Results were evaluated with repeated-measures analysis of variance, with P < 0.05 representing statistical significance. RESULTS Volunteers were 25 ± 5 years of age (mean ± SD), 175 ± 7 cm tall, and weighed 63 ± 10 kg. Core temperature remained constant (≈37°C) throughout each study day. At vasoconstriction, mean skin temperatures were 33.2°C (95% confidence interval [CI]: 32.0°C, 34.4°C), 33.5°C (95% CI: 32.3°C, 34.7°C), and 33.0°C (95% CI: 31.4°C, 34.6°C) at slow, medium, and fast skin-cooling rates, respectively. Mean skin temperatures at shivering were also comparable: 31.4°C (95% CI: 30.3°C, 32.5°C), 31.5°C (95% CI: 30.2°C, 32.8°C), and 30.7°C (95% CI: 28.9°C, 32.5°C), respectively. CONCLUSIONS Onset of vasoconstriction and shivering occurred at similar mean skin temperatures with all 3 cooling rates. Aggressive surface cooling can thus be used in thermoregulatory studies and for induction of therapeutic hypothermia without provoking dynamic thermoregulatory defenses.
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Abstract
Therapeutic hypothermia may be useful in various circumstances including stroke. However, core body temperature is normally tightly regulated. Even mild hypothermia in conscious subjects thus provokes vigorous thermoregulatory defenses which are potentially harmful in fragile patients. Furthermore, thermoregulatory responses are effective, which reduces the rate at which hypothermia can be induced. Drugs are thus often given to blunt normal thermoregulatory defenses. General anesthetics profoundly impair thermoregulatory control, but prolonged general anesthesia is rarely practical or appropriate. A variety of other drugs have therefore been evaluated. Most opioids only slightly impair thermoregulatory defenses, but meperidine is considerably more effective than equipotent doses of other opioids. The central alpha-2 agonists clonidine and dexmedetomidine are also useful. However, the best overall approach to inducing thermal tolerance appears to be a combination of buspirone and meperidine, which reduces the core temperature triggering shivering to about 33.5 degrees C in doses that maintain adequate ventilation.
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Affiliation(s)
- Daniel I Sessler
- Department of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio 44195, USA.
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12
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Kimberger O, Kurz A. Thermoregulatory management for mild therapeutic hypothermia. Best Pract Res Clin Anaesthesiol 2009; 22:729-44. [PMID: 19137813 DOI: 10.1016/j.bpa.2007.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In recent years the use of mild therapeutic hypothermia as a means of neuroprotection has become an important concept for treatment after cerebral ischemic hypoxic injury. Mild therapeutic hypothermia has been shown to improve outcome after out-of-hospital cardiac arrest, and many studies suggest a beneficial effect of mild therapeutic hypothermia on patient outcome after traumatic brain injury, cerebrovascular damage and neonatal asphyxia. This review article explores the numerous possibilities and methods for the induction of mild therapeutic hypothermia, reviews thermoregulatory management during maintenance and discusses associated risks and complications.
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Affiliation(s)
- Oliver Kimberger
- Department of Anaesthesiology, General Intensive Core and Pain Medicine, Medical University of Vienna, Austria.
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Abstract
Most clinically available thermometers accurately report the temperature of whatever tissue is being measured. The difficulty is that no reliably core-temperature-measuring sites are completely noninvasive and easy to use-especially in patients not undergoing general anesthesia. Nonetheless, temperature can be reliably measured in most patients. Body temperature should be measured in patients undergoing general anesthesia exceeding 30 min in duration and in patients undergoing major operations during neuraxial anesthesia. Core body temperature is normally tightly regulated. All general anesthetics produce a profound dose-dependent reduction in the core temperature, triggering cold defenses, including arteriovenous shunt vasoconstriction and shivering. Anesthetic-induced impairment of normal thermoregulatory control, with the resulting core-to-peripheral redistribution of body heat, is the primary cause of hypothermia in most patients. Neuraxial anesthesia also impairs thermoregulatory control, although to a lesser extent than does general anesthesia. Prolonged epidural analgesia is associated with hyperthermia whose cause remains unknown.
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Affiliation(s)
- Daniel I Sessler
- Department of Outcomes Research, The Cleveland Clinic-P77, Cleveland, Ohio 44195, USA.
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Pottie RG, Dart CM, Perkins NR, Hodgson DR. Effect of hypothermia on recovery from general anaesthesia in the dog. Aust Vet J 2007; 85:158-62. [PMID: 17397389 DOI: 10.1111/j.1751-0813.2007.00128.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To discern the effects of anaesthesia protocols and decreasing core body temperature on time to recovery from general anaesthesia. MATERIALS AND METHODS Healthy adult dogs undergoing desexing surgery were enrolled. More excitable dogs were premedicated with intramuscular acepromazine and morphine; calmer dogs were not premedicated. Anaesthesia was induced using halothane, isoflurane or sevoflurane delivered by mask, or by intravenous propofol, and maintained in standard fashion using one of the three inhalant agents. Thermostat controlled heat mats were used during surgical preparation and surgery. Oesophageal temperature was recorded throughout surgery. The time from cessation of anaesthetic administration until the dog successfully raised itself to sternal recumbency was considered the time of recovery. RESULTS Sixty-nine dogs completed the study, 42 males anaesthetised for 60.4 +/- 20.5 min, and 27 females anaesthetised for 85.4 +/- 33.2 min. Oesophageal temperature at the end of surgery was 36.8 +/- 0.80 degrees C. Oesophageal temperature had a significant effect on recovery time, with lower temperatures contributing to slower recoveries. Premedication significantly lengthened recovery times. The choice of induction or maintenance anaesthetic agent had no effect on recovery time. DISCUSSION Hypothermia is a common complication of general anaesthesia and surgery. Amongst other deleterious effects, it is associated with slower recovery from anaesthesia, likely due to a number of different mechanisms.
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Affiliation(s)
- R G Pottie
- University Veterinary Centre, University of Sydney, Camden NSW 2570, Australia.
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Delaney KA, Vassallo SU, Larkin GL, Goldfrank LR. Rewarming rates in urban patients with hypothermia: prediction of underlying infection. Acad Emerg Med 2006; 13:913-21. [PMID: 16946289 DOI: 10.1197/j.aem.2006.05.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In the urban setting, hypothermia is commonly associated with illness or intoxication, with death often secondary to infection. OBJECTIVES To evaluate factors that affect the rewarming rate (RWR) and the ability of the RWR and other clinical markers to predict the presence or absence of underlying infection in an adult urban population. METHODS This was a prospective observational study of hypothermic patient visits to a large emergency department. Serial temperatures were obtained during rewarming to construct rewarming curves. Rewarming modalities selected by emergency physicians were correlated with admission temperatures. Univariate associates of RWR and infection were assessed. RESULTS The authors identified 96 patient visits. The median temperature was 89.5 degrees F (31.9 degrees C; range, 73.0 degrees F to 95.0 degrees F [22.8 degrees C to 35.0 degrees C]). Thirteen patients had temperatures of < 80.0 degrees F (26.0 degrees C). Seven died within 14 hours of presentation; six, of infection. No patient experienced ventricular fibrillation. Potential candidate predictors of infection from a multivariate analysis were a RWR of < 1.80 degrees F (1.0 degrees C) per hour and a serum albumin of < 2.7 g/dL. Rapid rewarming was associated with the absence of infection and a temperature below 86.0 degrees F (30.0 degrees C). In patients without significant underlying illness, rewarming rates appeared to be independent of the modality of rewarming. CONCLUSIONS Rewarming rates reflect intrinsic capacity for thermogenesis. Increased RWRs were associated with the absence of infection. The achievement of normothermia did not prevent death in infected patients. Initiation of invasive rewarming in urban patients with hypothermia who have not had hypothermic cardiac arrest may be unwarranted. Management of this population should emphasize support, detection, and treatment of underlying illness.
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Affiliation(s)
- Kathleen A Delaney
- Division of Emergency Medicine/Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8579, USA.
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Komatsu R, Sengupta P, Cherynak G, Wadhwa A, Sessler DI, Liu J, Hurst HE, Lenhardt R. Doxapram only slightly reduces the shivering threshold in healthy volunteers. Anesth Analg 2005; 101:1368-1373. [PMID: 16243996 PMCID: PMC1552102 DOI: 10.1213/01.ane.0000180198.13467.df] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We determined the effects of doxapram on the major autonomic thermoregulatory responses in humans. Nine healthy volunteers were studied on 2 days: control and doxapram (IV infusion to a plasma concentration of 2.4 +/- 0.8, 2.5 +/- 0.9, and 2.6 +/- 1.1 microg/mL at the sweating, vasoconstriction, and shivering thresholds, respectively). Each day, skin and core temperatures were increased to provoke sweating, then reduced to elicit peripheral vasoconstriction and shivering. We determined the sweating, vasoconstriction, and shivering thresholds with compensation for changes in skin temperature. Data were analyzed with paired t-tests and presented as mean +/- sd; P < 0.05 was considered statistically significant. Doxapram did not change the sweating (control: 37.5 degrees +/- 0.4 degrees C, doxapram: 37.3 degrees +/- 0.4 degrees C; P = 0.290) or the vasoconstriction threshold (36.8 degrees +/- 0.7 degrees C versus 36.4 degrees +/- 0.5 degrees C; P = 0.110). However, it significantly reduced the shivering threshold from 36.2 degrees +/- 0.5 degrees C to 35.7 degrees +/- 0.7 degrees C (P = 0.012). No sedation or symptoms of panic were observed on either study day. The observed reduction in the shivering threshold explains the drug's efficacy for treatment of postoperative shivering; however, a reduction of only 0.5 degrees C is unlikely to markedly facilitate induction of therapeutic hypothermia as a sole drug.
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Affiliation(s)
- Ryu Komatsu
- Research Fellow, Outcomes Research™ Institute, University of Louisville
| | - Papiya Sengupta
- Research Fellow, Outcomes Research™ Institute, University of Louisville
| | - Grigory Cherynak
- Resident, Department of Anesthesiology & Perioperative Medicine, University of Louisville (current address: Assistant Professor, Department of Anesthesiology, Oklahoma University Health Sciences Center)
| | - Anupama Wadhwa
- Assistant Professor, Outcomes Research™ Institute and Department of Anesthesiology & Perioperative Medicine, University of Louisville
| | - Daniel I. Sessler
- Vice Dean for Research and Associate Vice President for Health Affairs; Director Outcomes Research™ Institute; Interim Chair and Lolita & Samuel Weakley Distinguished Professor of Anesthesiology, University of Louisville
| | - Jin Liu
- Graduate Student, Department of Pharmacology and Toxicology, University of Louisville
| | - Harrell E. Hurst
- Professor, Department of Pharmacology and Toxicology, University of Louisville
| | - Rainer Lenhardt
- Assistant Professor and Vice Chair, Outcomes Research™ Institute and Department of Anesthesiology & Perioperative Medicine; Director Neurosciences Intensive Care Unit, University of Louisville
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Röhm KD, Riechmann J, Boldt J, Schuler S, Suttner SW, Piper SN. THIS ARTICLE HAS BEEN RETRACTED Physostigmine for the prevention of postanaesthetic shivering following general anaesthesia - a placebo-controlled comparison with nefopam. Anaesthesia 2005; 60:433-8. [DOI: 10.1111/j.1365-2044.2005.04157.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lin CM, Neeru S, Doufas AG, Liem E, Shah YM, Wadhwa A, Lenhardt R, Bjorksten A, Sessler DI, Kurz A. Dantrolene Reduces the Threshold and Gain for Shivering. Anesth Analg 2004; 98:1318-24, table of contents. [PMID: 15105208 PMCID: PMC1454474 DOI: 10.1213/01.ane.0000108968.21212.d7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Dantrolene is used for treatment of life-threatening hyperthermia, yet its thermoregulatory effects are unknown. We tested the hypothesis that dantrolene reduces the threshold (triggering core temperature) and gain (incremental increase) of shivering. Healthy volunteers were evaluated on 2 random days: control and dantrolene (approximately 2.5 mg/kg plus a continuous infusion). In Study 1, 9 men were warmed until sweating was provoked and then cooled until arteriovenous shunt constriction and shivering occurred. Sweating was quantified on the chest using a ventilated capsule. Absolute right middle fingertip blood flow was quantified using venous-occlusion volume plethysmography. A sustained increase in oxygen consumption identified the shivering threshold. In Study 2, 9 men were given cold lactated Ringer's solution i.v. to reduce core temperature approximately 2 degrees C/h. Cooling was stopped when shivering intensity no longer increased with further core cooling. The gain of shivering was the slope of oxygen consumption versus core temperature regression. In Study 1, sweating and vasoconstriction thresholds were similar on both days. In contrast, shivering threshold decreased 0.3 +/- 0.3 degrees C, P = 0.004, on the dantrolene day. In Study 2, dantrolene decreased the shivering threshold from 36.7 +/- 0.2 to 36.3 +/- 0.3 degrees C, P = 0.01 and systemic gain from 353 +/- 144 to 211 +/- 93 mL.min(-1).degrees C(-1), P = 0.02. Thus, dantrolene substantially decreased the gain of shivering, but produced little central thermoregulatory inhibition. IMPLICATIONS Dantrolene substantially decreases the gain of shivering but produces relatively little central thermoregulatory inhibition. It thus seems unlikely to prove more effective than conventional muscle relaxants for treatment of life-threatening hyperthermia.
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Affiliation(s)
- Chun-Ming Lin
- Research Fellow, Outcomes Research™ Institute, University of Louisville
| | - Sharma Neeru
- Research Fellow, Department of Anesthesia, Washington University
| | - Anthony G. Doufas
- Assistant Professor, Outcomes Research™ Institute and Department of Anesthesiology, University of Louisville
| | - Edwin Liem
- Assistant Professor, Outcomes Research™ Institute and Department of Anesthesiology, University of Louisville
| | - Yunus Muneer Shah
- Research Fellow, Outcomes Research™ Institute, University of Louisville
| | - Anupama Wadhwa
- Research Fellow, Outcomes Research™ Institute, University of Louisville
| | - Rainer Lenhardt
- Assistant Director, Outcomes Research™ Institute; Assistant Professor, Department of Anesthesiology, University of Louisville
| | - Andrew Bjorksten
- Clinical Research Scientist, Department of Anaesthesia and Pain Management, Royal Melbourne Hospital
| | - Daniel I. Sessler
- Associate Dean for Research, Director Outcomes Research™ Institute, Lolita and Samuel Weakley Distinguished University Research Chair, Professor of Anesthesiology and Pharmacology, University of Louisville
| | - Andrea Kurz
- Professor and Chair, Department of Anesthesia, University of Bern; Associate Professor, Department of Anesthesia, Washington University; Professor and Associate Director, Outcomes Research™ Institute, University of Louisville
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Okuyama K, Matsukawa T, Ozaki M, Sessler DI, Nishiyama T, Imamura M, Kumazawa T. Doxapram produces a dose-dependent reduction in the shivering threshold in rabbits. Anesth Analg 2003; 97:759-762. [PMID: 12933397 DOI: 10.1213/01.ane.0000076062.62939.91] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Dopamine is a thermoregulatory neurotransmitter that provokes hypothermia when injected in or near the hypothalamus. Doxapram stimulates release of dopamine from carotid bodies, but is known to have central effects that are probably, at least in part, similarly mediated. We thus tested the hypothesis that doxapram produces a substantial, dose-dependent reduction in the shivering threshold in rabbits. Twenty-four rabbits, anesthetized with isoflurane, were randomly assigned to 1) saline (control), 2) 0.25 mg x kg(-1) x h(-1) doxapram, or 3) 0.50 mg x kg(-1) x h(-1) doxapram. These doses are within the recommended range for humans. Body temperature was reduced at a rate of 2 degrees to 3 degrees C/h by perfusing water at 10 degrees C through a U-shaped thermode positioned in the colon. Core temperatures were recorded from the distal esophagus. A blinded observer evaluated shivering. Core temperature at the onset of shivering defined the threshold. Data were analyzed with a one-way analysis of variance; P < 0.05 was considered statistically significant. Hemodynamic and respiratory responses were comparable in the groups. The control rabbits shivered at 36.3 degrees +/- 0.3 degrees C, those given 0.25 mg x kg(-1) x h(-1) doxapram shivered at 34.8 degrees +/- 0.5 degrees C, and those given 0.50 mg x kg(-1) x h(-1) shivered at 33.7 degrees +/- 0.6 degrees C. All the shivering thresholds significantly (P < 0.001) differed from one another. The magnitude of this inhibition, if similar in humans, would be clinically important.
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Affiliation(s)
- Katsumi Okuyama
- Departments of Anesthesia, *University of Yamanashi, Faculty of Medicine, Yamanashi; †Tokyo Women's Medical University, and ‡Tokyo University School of Medicine, Tokyo, Japan; and §Outcomes Research™ Institute and Departments of Anesthesiology, University of Louisville, Louisville, Kentucky
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Sessler DI. Skin-temperature gradients are a validated measure of fingertip perfusion. Eur J Appl Physiol 2003; 89:401-2; author reply 403-4. [PMID: 12736848 DOI: 10.1007/s00421-003-0812-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2003] [Indexed: 10/22/2022]
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Fritz HG, Hoff H, Hartmann M, Karzai W, Schwarzkopf KRG. The effects of urapidil on thermoregulatory thresholds in volunteers. Anesth Analg 2002; 94:626-30; table of contents. [PMID: 11867387 DOI: 10.1097/00000539-200203000-00027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED In a previous study we have shown that the antihypertensive drug, urapidil, stops postanesthetic shivering. One possible mechanism in the inhibition of postanesthetic shivering by urapidil may be alterations in thermoregulatory thresholds. We therefore studied the effects of urapidil on vasoconstriction and shivering thresholds during cold-induced shivering in volunteers. Seven healthy male volunteers were cooled by an infusion of saline at 4 degrees C on two study days separated by 48 h. Thermoregulatory vasoconstriction was estimated using forearm minus fingertip skin-temperature gradients, and values exceeding 0 degrees C were considered to represent significant vasoconstriction. The rectal core temperatures at the beginning of shivering and at vasoconstriction were considered the thermoregulatory thresholds. Before cooling, either 25 mg of urapidil or placebo was administered randomly and blindly to each volunteer. When shivering occurred continuously for 10 min, another 25 mg of urapidil was administered IV to completely stop shivering. Urapidil led to a decrease in core temperature at vasoconstriction and shivering threshold by 0.4 degrees C plus/minus 0.2 degrees C (P < 0.001) and 0.5 degrees C plus/minus 0.3 degrees C (P < 0.01), respectively. Oxygen consumption increased during shivering by 70% plus/minus 30% (P < 0.01) in comparison with baseline and decreased levels after shivering stopped, despite the continued low core temperature. Our investigation shows that urapidil stops postanesthetic shivering by decreasing important thermoregulatory thresholds. This means that shivering, not hypothermia, is treated, and hypothermia will need more attention in the postanesthesia care unit. IMPLICATIONS In this study we show that the antihypertensive drug urapidil stops cold-induced shivering and decreases normal thermoregulatory responses, i.e., the thresholds for vasoconstriction and shivering, in awake volunteers.
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Affiliation(s)
- Harald G Fritz
- Klinik fuer Anaesthesiologie und Intensivtherapie Klinikum and Apotheke des Klinikums, Friedrich-Schiller-Universitaet, Jena, Germany.
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Piper SN, Röhm KD, Maleck WH, Fent MT, Suttner SW, Boldt J. Dolasetron for preventing postanesthetic shivering. Anesth Analg 2002; 94:106-11, table of contents. [PMID: 11772810 DOI: 10.1097/00000539-200201000-00020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED We designed this study to assess the efficacy of dolasetron compared with clonidine and placebo in prophylaxis of postanesthetic shivering. We included 90 patients undergoing elective abdominal or urologic surgery. The patients were randomly assigned to one three groups (each group n = 30) using a double-blinded study protocol: Group A received 12.5 mg dolasetron, Group B 3 microg/kg clonidine, and Group C saline 0.9% as placebo. The medication was given after the induction of anesthesia. Postanesthetic shivering was judged by using a five-point scale. In the Clonidine group, 86.6% showed no shivering, whereas in the Dolasetron and Placebo groups, only 63.3% and 66.6%, respectively, were symptom free. Only clonidine, but not dolasetron, significantly reduced the incidence and the severity of shivering. We conclude that clonidine is effective in preventing shivering when given before surgery, whereas dolasetron, at the dose used, is not effective. IMPLICATIONS Shivering, an irregular muscular fasciculation lasting longer than 15 s, is a common complication secondary to general anesthesia. We compared dolasetron with clonidine (an established antishivering drug) in the prevention of postanesthetic shivering. Dolasetron 12.5 mg was not effective.
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Affiliation(s)
- Swen N Piper
- Department of Anesthesiology and Critical Care Medicine, Klinikum Ludwigshafen, Ludwigshafen, Germany
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Maurer AJ, Sessler DI, Eger EI, Sonner JM. The nonimmobilizer 1,2-dichlorohexafluorocyclobutane does not affect thermoregulation in the rat. Anesth Analg 2000; 91:1013-6. [PMID: 11004066 DOI: 10.1097/00000539-200010000-00045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inhaled and other anesthetics profoundly affect the central nervous system, causing amnesia, immobility in the face of noxious stimulation, and depression of thermoregulation. Nonimmobilizers, inhaled compounds whose lipophilicity suggests that they should be anesthetics, do not produce immobility, but they do cause amnesia. Their effects on thermoregulation were the subject of the present study. We gave eight rats isoflurane on one occasion and the nonimmobilizer 2N (1,2-dichlorolhexafluorocyclobutane) on another. We measured the effect of various concentrations of each compound on thermoregulation provoked by body cooling. The specific outcome was increased metabolism, as reflected in increased output of carbon dioxide. Isoflurane decreased the temperature threshold for such increases and the maximum response intensity, doing so in a concentration-dependent manner, whereas 2N had a minimal or no effect at any concentration up to 0.9 minimum alveolar concentration (estimated from its lipophilicity). Thus, 2N may be a useful tool for studies of the mechanisms mediating the thermoregulatory depression produced by anesthetics: 2N should not affect such a mechanism.
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Affiliation(s)
- A J Maurer
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California 94143-0464, USA
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Abstract
Most postanaesthetic shivering-like tremor is normal thermoregulatory shivering in response to core hypothermia. Therefore, shivering will be prevented by maintaining intraoperative normothermia. Other thermoregulatory-related shivering is caused by the release of cytokines by the surgical procedure. Non-thermoregulatory shivering, occurring in normothermic patients, is caused by other aetiologies such as postoperative pain. It is thus likely that adequate treatment of postoperative pain will ameliorate non-thermoregulatory tremor. In addition, the administration of antipyretic drugs reduces shivering in patients after cardiopulmonary bypass surgery.
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Affiliation(s)
- E P Horn
- Outcomes Research Group and Department of Anesthesiology, University Hospital Eppendorf, Hamburg, Germany.
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Abstract
Homeothermic species such as birds and mammals require an almost constant internal body temperature to preserve normal physiological and metabolic function. When the internal temperature deviates significantly from normal, metabolic function deteriorates and death may result. The efficiency of the thermoregulatory system is highly affected by the administration of medication and by illnesses. Hypothermia may result, especially when these conditions are associated with exposure to a cold environment. Because such conditions exist during anaesthesia and surgery, the understanding of the physiology of the thermoregulatory system and the associated perianaesthetic thermal disturbances is essential to a proper intraoperative management. The purpose of this review is to provide clinicians with a better understanding of these principles, and also to elaborate on the most recent advances in this field, which should help to improve intraoperative anaesthetic temperature management.
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Affiliation(s)
- A J Davis
- Department of Anaesthesia, The Hospital for Sick Children, University of Toronto, Ontario, Canada
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