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Pirouzram A, Wikström M, Larzon T, Tamás É, Nilsson KF. Induced Moderate Hypothermia in Aortic Rupture With Retroperitoneal Bleeding: A Randomized Porcine Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024:15569845241253234. [PMID: 38828939 DOI: 10.1177/15569845241253234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Induced hypothermia improves outcome in aortic arch surgery, neonatal neurointensive care, and transplant surgery for example. In contrast, spontaneous hypothermia has been associated with worse outcomes in patients suffering from hemorrhagic shock, mostly explained by its adverse effects on the coagulation system. We investigated if induced hypothermia would impair short-term survival in experimental aortic rupture with retroperitoneal bleeding. METHODS Anesthetized pigs were randomized into 2 groups: hypothermia by peritoneal lavage of ice-cold Ringer's acetate and external cooling (n = 10) and normothermia (n = 10). Aortic rupture with retroperitoneal bleeding was induced by endovascular means creating a 6 mm hole in the retroperitoneal portion of abdominal aorta. Survival (primary outcome), hemodynamics, and arterial blood gases including lactate were collected and analyzed up to 180 min after aortic rupture. RESULTS The body temperature (mean ± standard deviation) in the hypothermic group was 31.5 ± 1.0 °C and 38.7 ± 0.4 °C in the normothermic group at the time for aortic rupture. Survival up to 180 min after the retroperitoneal bleeding was significantly higher in the hypothermic compared with the normothermic group (P = 0.023). CONCLUSIONS Induced hypothermia did not impair survival in this experimental retroperitoneal aortic bleeding model in anesthetized pigs. This finding may indicate a minor role for the coagulation system in this type of bleeding.
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Affiliation(s)
- Artai Pirouzram
- Department of Cardiothoracic and Vascular Surgery, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Maria Wikström
- Department of General Surgery, Central Hospital in Karlstad, Sweden
- School of Medical Sciences, Örebro University, Sweden
| | - Thomas Larzon
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Sweden
| | - Éva Tamás
- Department of Cardiothoracic and Vascular Surgery, and Department of Health, Medicine and Caring Sciences, Linköping University, Sweden
| | - Kristofer F Nilsson
- School of Medical Sciences, Örebro University, Sweden
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Sweden
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Schauer SG, April MD, Fisher AD, Weymouth WL, Maddry JK, Gillespie KR, Salinas J, Cap AP. Hypothermia in the Combat Trauma Population. PREHOSP EMERG CARE 2022; 27:934-940. [PMID: 36037100 DOI: 10.1080/10903127.2022.2119315] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The MARCH (Massive hemorrhage, Airway, Respirations, Circulation, and Hypothermia/Head injuries) algorithm taught to military medics includes interventions to prevent hypothermia. As possible sequelae from major trauma, hypothermia is associated with coagulopathy and lower survival. This paper sought to define hypothermia within our combat trauma population using an outcomes-based method, and determine clinical variables associated with hypothermia. METHODS This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry focused on casualties who received prehospital care. A receiver operating curve was constructed and Youden's index was used to define hypothermia within the predetermined population based on mortality risk. A multivariable regression model was used to identify associations. RESULTS There were 23,243 encounters that met the inclusion criteria for this study with patients having received prehospital care and documentation of at least one emergency department temperature. An optimal threshold of 36.2° C was found to predict mortality; 3,159 casualties had temperatures below this threshold (14%). Survival to discharge was lower among casualties with hypothermia (91% versus 98%). Hypothermic casualties were less likely to undergo blanket application (38% versus 40%). However, they had higher proportions with Hypothermia Prevention and Management Kit application (11% versus 7%) and radiant warming (2% versus 1%). On multivariable regression modeling, none of the hypothermia interventions were associated with a decreased likelihood of hypothermia. Non-hypothermia interventions associated with hypothermia included prehospital intubation (OR 1.57, 95% CI 1.45-1.69) and blood product administration. CONCLUSIONS Hypothermia, including a single recorded low temperature in the patient care record, was associated with worse outcomes in this combat trauma population. Prehospital intubation was most strongly associated with developing hypothermia. Prehospital warming interventions were not associated with a reduction in hypothermia risk. Our dataset suggests that current methods for prehospital warming are inadequate.
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Affiliation(s)
- Steven G Schauer
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 40th Forward Resuscitation and Surgical Detachment, Fort Carson, Colorado, USA
| | - Andrew D Fisher
- University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Texas Army National Guard, Austin, Texas, USA
| | - Wells L Weymouth
- 160th Special Operations Aviation Regiment, Hunter Army Airfield, Georgia, USA
| | - Joseph K Maddry
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 59th Medical Wing, JBSA Fort Sam Houston, Texas, USA
| | - Kevin R Gillespie
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Jose Salinas
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Patel M, Ramagaga N, Kruger D, Lehnerdt G, Mansoor I, Mohlala L, Rendel D, Zaheed F, Jordaan M, Mokhachane M, Nakwa FL, Mphahlele R. Hypothermia in neonates born by caesarean section at a tertiary hospital in South Africa. Front Pediatr 2022; 10:957298. [PMID: 36561484 PMCID: PMC9763723 DOI: 10.3389/fped.2022.957298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 11/04/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION neonatal hypothermia has previously been noted in a large proportion of neonates born through Caesarean section at Chris Hani Baragwanath Hospital (CHBAH), yet no study in South Africa specifically explores the extent and severity of the threat of hypothermia to this population of neonates. OBJECTIVES to describe the proportion and severity of neonatal hypothermia in infants born via Caesarean section at CHBAH as well as to document and describe possible contributing factors to neonatal hypothermia in this population. METHODS A neonatal unit's database records were reviewed for demographic information of patients and their mothers, clinical characteristics, body temperature and outcomes. Comparisons between normothermic and hypothermic neonates were performed. RESULTS Forty-one percent of neonates born via Caesarean section had hypothermia at birth, of whom 71%, 27% and 2% had mild, moderate and severe hypothermia, respectively. Prevalence of admission hypothermia was 42%. On average, neonates were born at term and were of normal birth weight. No maternal factors were found to be statistically significant. Bag-mask ventilation (BMV) and cardiopulmonary resuscitation (CPR) [3.4% vs. 0.7%, p-0.033; OR 2.67 (95% CI: 1.06-6.77)] and an elevated lactate [13.25 vs. 3.2 mmol/l, p-0.032; OR 1.13 (95% CI: 1.01-1.26)] were associated with hypothermia. In the multivariable logistic regression analysis hypothermia in neonates was associated with an elevated lactate. CONCLUSIONS Prevalence of hypothermia in neonates born by Caesarean section is high and further prospective studies are required to elucidate the factors contributing to this.
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Affiliation(s)
- Mariambibi Patel
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Neo Ramagaga
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Danielle Kruger
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Grace Lehnerdt
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Imraan Mansoor
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Lesedi Mohlala
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Dylan Rendel
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Fathima Zaheed
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Mimie Jordaan
- District Clinical Specialist Team, Johannesburg Health District, Johannesburg, South Africa
| | - Mantoa Mokhachane
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Firdose Lambey Nakwa
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa.,Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Ramatsimele Mphahlele
- District Clinical Specialist Team, Johannesburg Health District, Johannesburg, South Africa
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Rösli D, Schnüriger B, Candinas D, Haltmeier T. The Impact of Accidental Hypothermia on Mortality in Trauma Patients Overall and Patients with Traumatic Brain Injury Specifically: A Systematic Review and Meta-Analysis. World J Surg 2020; 44:4106-4117. [PMID: 32860141 PMCID: PMC7454138 DOI: 10.1007/s00268-020-05750-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 12/31/2022]
Abstract
Background Accidental hypothermia is a known predictor for worse outcomes in trauma patients, but has not been comprehensively assessed in a meta-analysis so far. The aim of this systematic review and meta-analysis was to investigate the impact of accidental hypothermia on mortality in trauma patients overall and patients with traumatic brain injury (TBI) specifically. Methods This is a systematic review and meta-analysis using the Ovid Medline/PubMed database. Scientific articles reporting accidental hypothermia and its impact on outcomes in trauma patients were included in qualitative synthesis. Studies that compared the effect of hypothermia vs. normothermia at hospital admission on in-hospital mortality were included in two meta-analyses on (1) trauma patients overall and (2) patients with TBI specifically. Meta-analysis was performed using a Mantel–Haenszel random-effects model. Results Literature search revealed 264 articles. Of these, 14 studies published 1987–2018 were included in the qualitative synthesis. Seven studies qualified for meta-analysis on trauma patients overall and three studies for meta-analysis on patients with TBI specifically. Accidental hypothermia at admission was associated with significantly higher mortality both in trauma patients overall (OR 5.18 [95% CI 2.61–10.28]) and patients with TBI specifically (OR 2.38 [95% CI 1.53–3.69]). Conclusions In the current meta-analysis, accidental hypothermia was strongly associated with higher in-hospital mortality both in trauma patients overall and patients with TBI specifically. These findings underscore the importance of measures to avoid accidental hypothermia in the prehospital care of trauma patients. Electronic supplementary material The online version of this article (10.1007/s00268-020-05750-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Rösli
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Haltmeier
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Hypothermia-rewarming: A Double-edged sword? Med Hypotheses 2019; 133:109387. [PMID: 31541781 DOI: 10.1016/j.mehy.2019.109387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 01/05/2023]
Abstract
Hypothermia is a condition in which the body's core temperature drops below 35.0 °C. Hypothermia is the opposite of hyperthermia, which the metabolism and body functions are abnormal. Severe hypothermia is a life-threatening problem that may cause atrial and ventricular dysrhythmias, coagulopathy, cardiac, and central nervous system depression. What is worse, it is fatal when untreated or treated improperly. Accidental deaths due to hypothermia resulting from immersion in cold water, especially involving naval fighters and maritime victims have occurred continually in the past years. Currently, the treatment of hypothermia has become a research focus. Rewarming is the only approach that should be considered for hypothermia treatment. However, the treatment is of low efficiency, and few active rewarming cases have been reported. It is well known that timely reperfusion is the best way to save the lives of patients with ischemia. Similarly, reoxygenation is effective for hypoxia. However, several studies have identified that improper reperfusion of ischemic tissues and reoxygenation of hypoxic tissues give rise to further injury. Analogically, this study attempts to propose the hypothesis that hypothermia-rewarming injury may also exist. When suffered from hypothermia, both the blood circulation and the oxygen supply in the body will be affected in a deficient state, an injury may also appear in the improper rewarming process. In a word, hypothermia-rewarming may be a double-edged sword.
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The relationship between neutrophil-lymphocyte ratio and onset of lactation among postpartum women: A prospective observational cohort study. Int J Nurs Stud 2019; 97:55-62. [PMID: 31181412 DOI: 10.1016/j.ijnurstu.2019.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 05/05/2019] [Accepted: 05/05/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Delayed onset of lactation is a key factor in the low rate of exclusive breast-feeding in 6 months after caesarean section. The mechanism of delayed onset of lactation is not clear. Milk production depends largely on mitochondrial adenosine triphosphate synthesis, and the neutrophil-lymphocyte ratio is closely related to mitochondrial deoxyribonucleic acid copy number and adenosine triphosphate production. Presently, it is unclear whether a difference in the neutrophil-lymphocyte ratio exists between those undergoing vaginal delivery and those undergoing caesarean delivery and, if so, whether the difference correlates to the time of onset of lactation. OBJECTIVES To identify whether the neutrophil-lymphocyte ratio at 24 hours after delivery is different between mothers delivering by caesarean section and those giving birth vaginally and whether the neutrophil-lymphocyte ratio is related to the delayed onset of lactation. DESIGN The study adopted a prospective cohort study design. SETTINGS Maternity units of an Obstetrics & Gynecology Hospital. PARTICIPANTS 327 mother-infant pairs who met inclusion/exclusion criteria and were followed up to the time of onset of lactation. METHODS Mother-infant pairs were allocated to the vaginal birth group or the caesarean section group according to birth method. The neutrophil-lymphocyte ratio was calculated as the absolute value of neutrophils divided by the absolute value of lymphocytes based on full blood counts. Before delivery, full blood counts were obtained from medical records. After delivery, blood samples were drawn 24 hours postpartum, and blood cells were classified and counted. The onset of lactation was confirmed by the maternal perception of breast fullness. The neutrophil-lymphocyte ratio and its relationship with lactation onset were analyzed by multivariable regression. RESULTS The neutrophil-lymphocyte ratios of both groups were elevated after delivery. Based on the covariance analysis, after adjusting for baseline full blood counts before delivery, the neutrophil-lymphocyte ratio in the caesarean group was higher than the ratio in the vaginal group after delivery (p = .000). In addition, after adjustment for confounding factors, multivariable regression analyses showed that an increased neutrophil-lymphocyte ratio was correlated with delayed onset of lactation (95% confidence interval 0.285-1.646). CONCLUSIONS The neutrophil-lymphocyte ratio in the caesarean section group was higher than that in the vaginal delivery group and was related to a delayed onset of lactation. Given the decreased mitochondrial copy number in the elevated neutrophil-lymphocyte ratio and therefore the associated reduction in adenosine triphosphate synthesis, these findings may elucidate the mechanism for delayed onset of lactation in caesarean section births.
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Li D, Henker R, Zhang F. Perianesthesia Measurement During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Procedure: A Case Report and Review of the Literature. J Perianesth Nurs 2019; 34:198-205. [DOI: 10.1016/j.jopan.2017.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/15/2017] [Accepted: 09/22/2017] [Indexed: 01/19/2023]
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Murtuza F, Farrier AJ, Venkatesan M, Smith R, Khan A, Uzoigwe CE, Chami G. Is there an association between body temperature and serum lactate levels in hip fracture patients? Ann R Coll Surg Engl 2015; 97:513-8. [PMID: 26274739 PMCID: PMC5210136 DOI: 10.1308/rcsann.2015.0012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2015] [Indexed: 11/22/2022] Open
Abstract
Introduction Hyperlactataemia is associated with adverse outcomes in trauma cases. It is thought to be the result of anaerobic respiration during hypoperfusion. This produces much less energy than complete aerobic glycolysis. Low body temperature in the injured patient carries an equally poor prognosis. Significant amounts of energy are expended in maintaining euthermia. Consequently, there may be a link between lactate levels and dysthermia. Hyperlactataemia may be indicative of inefficient energy production and therefore insufficient energy to maintain euthermia. Alternatively, significant amounts of available oxygen may be sequestered in thermoregulation, resulting in anaerobic respiration and lactate production. Our study investigated whether there is an association between lactate levels and admission body temperature in hip fracture patients. Furthermore, it looked at whether there is a difference in the mean lactate levels between hip fracture patients with low (<36.5°C), normal (36.5-37.5°C) and high (>37.5°C) body temperature on admission, and for patients who have low body temperature, whether there is a progressive rise in serum lactate levels as body temperature falls. Methods The admission temperature and serum lactate of 1,162 patients presenting with hip fracture were recorded. Patients were divided into the euthermic (body temperature 36.5-37.5°C), the pyrexial (>37.5°C) and those with low body temperature (<36.5°C). Admission lactate and body temperature were compared. Results There was a significant difference in age between the three body temperature groups (p=0.007). The pyrexial cohort was younger than the low body temperature group (mean: 78 vs 82 years). Those with low body temperature had a higher mean lactate level than the euthermic (2.2mmol/l vs 2.0mmol/l, p=0.03). However, there was no progressive rise in serum lactate level as admission temperature fell. Conclusions The findings suggest that in hip fracture patients, the body attempts initially to maintain euthermia, incurring an oxygen debt. This would explain the difference in lactate level between the low body temperature and euthermic cohorts. The fact that there is no correlation with the degree of temperature depression and lactate levels indicates that the body does not fuel thermohomeostasis indefinitely with oxygen. Instead, in part, it abandons thermoregulatory mechanisms. Consequently, in this population, active rewarming may be indicated rather than depending on patients' own thermogenic ability.
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Affiliation(s)
- F Murtuza
- University Hospitals of Leicester NHS Trust , UK
| | - A J Farrier
- North Tees and Hartlepool NHS Foundation Trust , UK
| | - M Venkatesan
- University Hospitals of Leicester NHS Trust , UK
| | - R Smith
- University Hospitals of Leicester NHS Trust , UK
| | - A Khan
- Kettering General Hospital NHS Foundation Trust , UK
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Lethal triad in severe burns. Burns 2014; 40:1492-6. [DOI: 10.1016/j.burns.2014.04.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/03/2014] [Accepted: 04/19/2014] [Indexed: 11/19/2022]
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Faizi M, Farrier AJ, Venkatesan M, Thomas C, Uzoigwe CE, Balasubramanian S, Smith RP. Is body temperature an independent predictor of mortality in hip fracture patients? Injury 2014; 45:1942-5. [PMID: 25458058 DOI: 10.1016/j.injury.2014.09.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 09/22/2014] [Accepted: 09/27/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Admission body temperature is a critical parameter in all trauma patients. Low admission temperature is strongly associated with adverse outcomes. We have previously shown, in a prospective study that low admission body temperature is common and associated with high mortality in hip fracture patients (Uzoigwe et al., 2014). However, no previous studies have evaluated whether admission temperature is an independent predictor of mortality in hip fracture patients after adjustment for the 7 recognised independent prognostic indicators (Maxwell et al., 2008). METHODS We retrospectively collated data on all patients presenting to our institution between June 2011 and February 2013 with a hip fracture. This included patients involved in the original prospective study (Uzoigwe et al., 2014). Admission tympanic temperature, measured on initial presentation at triage, was recorded. The prognosticators of age, gender, source of admission, abbreviated mental test score, haemoglobin, co-morbid disease and the presence or absence of malignancy were also recorded. Using multiple logistic regression, adjustment was made for these potentially confounding prognostic indicators of 30-day mortality, to determine if admission low body temperature were independently linked to mortality. RESULTS 1066 patients were included. 781 patients, involved in the original prospective study (Uzoigwe et al., 2014), presented in the relevant time frame and were included in the retrospective study. The mean age was 81. There were 273 (26%) men and 793 (74%) women. 407 (38%) had low body temperature (<36.5 °C). Adjustment was made for age, gender, source of admission, abbreviated mental test score, haemoglobin, co-morbid disease and the presence or absence of malignancy. Those with low body temperature had an adjusted odds ratio of 30-day mortality that was 2.1 times that of the euthermic (36.5–37.5 °C). CONCLUSIONS Low body temperature is strongly and independently associated with 30-day mortality in hip fracture patients.
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Prolonged induced hypothermia in hemorrhagic shock is associated with decreased muscle metabolism: a nuclear magnetic resonance-based metabolomics study. Shock 2014; 41:79-84. [PMID: 24052038 DOI: 10.1097/shk.0000000000000061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hemorrhagic shock is a leading cause of trauma-related death in war and is associated with significant alterations in metabolism. Using archived serum samples from a previous study, the purpose of this work was to identify metabolic changes associated with induced hypothermia in a porcine model of hemorrhagic shock. Twelve Yorkshire pigs underwent a standardized hemorrhagic shock and resuscitation protocol to simulate battlefield injury with prolonged evacuation to definitive care in cold environments. Animals were randomized to receive either hypothermic (33°C) or normothermic (39°C) limited resuscitation for 8 h, followed by standard resuscitation. Proton nuclear magnetic resonance spectroscopy was used to evaluate serum metabolites from these animals at intervals throughout the hypothermic resuscitation period. Animals in the hypothermic group had a significantly higher survival rate (P = 0.02) than normothermic animals. Using random forest analysis, a difference in metabolic response between hypothermic and normothermic animals was identified. Hypothermic resuscitation was characterized by decreased concentrations of several muscle-related metabolites including taurine, creatine, creatinine, and amino acids. This study suggests that a decrease in muscle metabolism as a result of induced hypothermia is associated with improved survival.
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Induced hypothermia reduces the hepatic inflammatory response in a swine multiple trauma model. J Trauma Acute Care Surg 2014; 76:1425-32. [PMID: 24854311 DOI: 10.1097/ta.0000000000000224] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mild therapeutic hypothermia following trauma has been introduced in several studies to reduce the posttraumatic inflammation and organ injury. In this study, we analyzed the effects of induced mild hypothermia (34°C) on the inflammation of the shock organs liver and kidney. METHODS In a porcine model of multiple trauma including blunt chest trauma, liver laceration, and hemorrhagic shock followed by fluid resuscitation, the influence of induced hypothermia on hepatic and renal damage and organ-specific inflammation were evaluated. A total of 40 pigs were randomly assigned to four groups, which were sham (anesthesia only) or trauma groups receiving either hypothermia or normothermia. The parameters analyzed were laboratory parameters (aspartate transaminase [AST], lactate dehydrogenase, urea, creatinine) as well as hepatic and renal cytokine expression determined by real-time polymerase chain reaction (interleukin 6 [IL-6], IL-8). Blinded analysis of histologic changes in the liver and kidney was performed. RESULTS Fifteen and a half hours following combined trauma, hepatic cytokine expression and liver damage were significantly increased in animals with normothermia compared with the respective sham group. Hypothermia, however, resulted in a fivefold reduced hepatic expression of IL-8 (mean ± SE, 2.4 ± 1.3; p = 0.01) when compared with the normothermic trauma group (IL-8, 12.8 ± 4.7). Accordingly, granulocyte infiltration and a histologic, semiquantitative score for liver injury were significantly higher in the normothermic trauma group. Serum AST levels raised significantly after trauma and normothermia compared with the respective sham group, while AST levels showed no difference from the sham groups in the hypothermic trauma group. In contrast, neither trauma nor hypothermia influenced the expression of IL-6 and IL-8 and tissue injury in the kidney. CONCLUSION Therapeutic hypothermia seems to attenuate the hepatic inflammatory response and the associated liver injury after severe trauma. Therefore, induced hypothermia might represent a potential therapeutic strategy to avoid posttraumatic organ dysfunction.
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Hildebrand F, Radermacher P, Ruchholtz S, Huber-Lang M, Seekamp A, Flohé S, van Griensven M, Andruszkow H, Pape HC. Relevance of induced and accidental hypothermia after trauma-haemorrhage-what do we know from experimental models in pigs? Intensive Care Med Exp 2014; 2:16. [PMID: 26266916 PMCID: PMC4512998 DOI: 10.1186/2197-425x-2-16] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 04/06/2014] [Indexed: 12/17/2022] Open
Abstract
Recent experimental research has either focused on the role of accidental hypothermia as part of the lethal triad after trauma or tried to elucidate the effects of therapeutically induced hypothermia on the posttraumatic course. Induced hypothermia seems to reduce the mortality in experimental models of trauma-haemorrhage. As potential mechanisms, a decrease of cellular metabolism, beneficial effects on haemodynamic function and an attenuation of the inflammatory response have been described. However, negative side effects of hypothermia have to be considered, such as impairment of the coagulatory function and immunosuppressive effects. Furthermore, the optimal strategy for the induction of hypothermia (magnitude, duration, timing, cooling rate, etc.) and subsequent rewarming remains unclear. Nevertheless, this piece of information is essential before considering hypothermia as a treatment strategy for severely injured patients. This review aims to elaborate the differences between accidental and induced hypothermia and to summarize the current knowledge of the potential therapeutic use of induced hypothermia suggested in porcine models of trauma-haemorrhage.
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Affiliation(s)
- Frank Hildebrand
- Department of Orthopedic Trauma and Reconstructive Surgery and Harald Tscherne Laboratory, University of Aachen, Pauwelsstraße 30, Aachen, 52074, Germany,
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Abstract
OBJECTIVES Accidental hypothermia increases mortality and morbidity after hemorrhage, but controversial data are available on the effects of therapeutic hypothermia. Therefore, we tested the hypothesis whether moderate pretreatment hypothermia would beneficially influence organ dysfunction during long-term, porcine hemorrhage and resuscitation. DESIGN Prospective, controlled, randomized study. SETTING University animal research laboratory. SUBJECTS Twenty domestic pigs of either gender. INTERVENTIONS Using an extracorporeal heat exchanger, anesthetized and instrumented animals were maintained at 38°C, 35°C, or 32°C core temperature and underwent 4 hours of hemorrhage (removal of 40% of the blood volume and subsequent blood removal/retransfusion to maintain mean arterial pressure at 30 mm Hg). Resuscitation comprised of hydroxyethyl starch and norepinephrine infusion titrated to maintain mean arterial pressure at preshock values. MEASUREMENTS AND MAIN RESULTS Before, immediately at the end of, and 12 and 22 hours after hemorrhage, we measured systemic and regional hemodynamics (portal vein, hepatic and right kidney artery ultrasound flow probes) and oxygen transport, and nitric oxide and cytokine production. Hemostasis was assessed by rotation thromboelastometry. Postmortem biopsies were analyzed for histomorphology (hematoxylin and eosin staining) and markers of apoptosis (kidney Bcl-xL and caspase-3 expression). Hypothermia at 32°C attenuated the shock-related lactic acidosis but caused metabolic acidosis, most likely resulting from reduced carbohydrate oxidation. Although hypothermia did not further aggravate shock-related coagulopathy, it caused a transitory attenuation of kidney and liver dysfunction, which was ultimately associated with reduced histological damage and more pronounced apoptosis. CONCLUSIONS During long-term porcine hemorrhage and resuscitation, moderate pretreatment hypothermia was associated with a transitory attenuation of organ dysfunction and less severe histological tissue damage despite more pronounced metabolic acidosis. This effect is possibly due to a switch from necrotic to apoptotic cell death, ultimately resulting from reduced tissue energy deprivation during the shock phase.
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Abstract
We have previously demonstrated survival benefit to induced hypothermia in a porcine model of controlled hemorrhagic shock simulating an associated delay to definitive care. In the current study, we wished to evaluate the effects of environmental hypothermia in a porcine model of hemorrhagic shock with the addition of polytrauma. Sixteen pigs were randomized to normothermic (39°C, n = 7) or hypothermic (34°C, n = 9) groups. The model included instrumentation, chest injury (captive bolt device), hemorrhage to systolic blood pressure (SBP) of ∼50 mmHg, and crush liver injury. Animals received limited fluid resuscitation for a 1-h period with goal SBP of greater than 80 mmHg and ice packs or warming blankets to achieve goal temperatures, followed by full resuscitation with goal SBP of greater than 90 mmHg, adequate urine output, and hemoglobin by protocol for 20 h. Survivors were observed for an additional 24 h with end points including mortality, markers of organ injury, and neurologic function. There were no differences in survival between the groups (mortality = 1/9, hypothermia group vs. 2/7, normothermia group, P = 0.39). Markers of organ injury were elevated in the hypothermia group at 24 h after injury but were identical between groups at the end of the experimental protocol (48 h after injury). There were no noted differences in neurologic function between the two groups. Environmental hypothermia in a model of polytrauma and hemorrhagic shock was not associated with worse outcomes.
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Abstract
PURPOSE OF REVIEW Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an important therapeutic option for selected patients with peritoneal surface malignancies. This aggressive multimodality treatment is complex, not only regarding surgical technique, but also regarding anesthesia. The present review represents our experience in anesthetic care. RECENT FINDINGS Improved prognosis compared with systemic chemotherapy alone has recently been demonstrated for cytoreductive surgery when combined with intraoperative intracavitary hyperthermic chemotherapy. Anesthetic management of HIPEC is further impacted by these developments. In addition to the ambitious, long-lasting surgery, HIPEC causes significant fluid, blood and protein losses, increased intra-abdominal pressure, systemic hyperthermia, and increased metabolic rate, leading to relevant pathophysiological alterations, and therefore represents a challenge for anesthetist and critical care physicians. SUMMARY Anesthetic management importantly contributes to the containment of the perioperative complications of HIPEC. An appreciation of the technical aspects and physiologic disruptions associated with intra-abdominal HIPEC is critical to ensure effective anesthetic management. Although data on this specialized surgical procedure are scarce, some referral centers have accumulated extensive experience. This article reviews the current knowledge about the anesthesiological and intensive care management of patients undergoing HIPEC. It pinpoints strategies for perioperative monitoring as well as illustrates alterations in hemodynamic, hematopoetic, and fluid hemostasis.
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Alam HB. Translational barriers and opportunities for emergency preservation and resuscitation in severe injuries. Br J Surg 2012; 99 Suppl 1:29-39. [PMID: 22441853 DOI: 10.1002/bjs.7756] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hypothermia is commonly used for organ and tissue preservation in multiple clinical settings, but its role in the management of injured patients remains controversial. There is no doubt that temperature modulation is a powerful tool, and hypothermia has been shown to protect cells during ischaemia and reperfusion, decrease organ damage and improve survival. Yet hypothermia is a double-edged sword: unless carefully managed, its induction can be associated with a number of complications. METHODS A literature review was performed to include important papers that address the impact of hypothermia on key biological processes, and explore the potential therapeutic role of hypothermia in trauma/haemorrhage models. RESULTS No clinical studies have been conducted to test the therapeutic benefits of hypothermia in injured patients. However, numerous well designed animal studies support this concept. Despite excellent preclinical data, there are several potential barriers to translating hypothermia into clinical practice. CONCLUSION Therapeutic hypothermia is a promising life-saving strategy. Appropriate patient selection requires a thorough understanding of how temperature modulation affects various biological mechanisms.
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Affiliation(s)
- H B Alam
- Harvard Medical School, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, Massachusetts 02114, USA.
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Sundberg J, Estrada C, Jenkins C, Ray J, Abramo T. Hypothermia is associated with poor outcome in pediatric trauma patients. Am J Emerg Med 2011; 29:1019-22. [DOI: 10.1016/j.ajem.2010.06.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 05/28/2010] [Accepted: 06/03/2010] [Indexed: 11/16/2022] Open
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Gutiérrez-Cruz AR, Soto-Rivera B, León-Chávez BA, Suaste-Gómez E, Martinez-Fong D, González-Barrios JA. Active core rewarming avoids bioelectrical impedance changes in postanesthetic patients. BMC Anesthesiol 2011; 11:2. [PMID: 21324200 PMCID: PMC3053227 DOI: 10.1186/1471-2253-11-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 02/16/2011] [Indexed: 11/18/2022] Open
Abstract
Background Postoperative hypothermia is a common cause of complications in patients who underwent laparoscopic cholecystectomy. Hypothermia is known to elicit electrophysiological, biochemical, and cellular alterations thus leading to changes in the active and passive membrane properties. These changes might influence the bioelectrical impedance (BI). Our aim was to determine whether the BI depends on the core temperature. Methods We studied 60 patients (52 female and 8 male) age 40 to 80 years with an ASA I-II classification that had undergone laparoscopic cholecystectomy under balanced inhalation anesthesia. The experimental group (n = 30) received active core rewarming during the transanesthetic and postanesthesic periods. The control group (n = 30) received passive external rewarming. The BI was recorded by using a 4-contact electrode system to collect dual sets of measurements in the deltoid muscle. The body temperature, hemodynamic variables, respiratory rate, blood-gas levels, biochemical parameters, and shivering were also measured. The Mann-Whitney unpaired t-test was used to determine the differences in shivering between each group at each measurement period. Measurements of body temperature, hemodynamics variables, respiratory rate, and BI were analyzed using the two-way repeated-measures ANOVA. Results The gradual decrease in the body temperature was followed by the BI increase over time. The highest BI values (95 ± 11 Ω) appeared when the lowest values of the temperature (35.5 ± 0.5°C) were reached. The active core rewarming kept the body temperature within the physiological range (over 36.5°C). This effect was accompanied by low stable values (68 ± 3 Ω) of BI. A significant decrease over time in the hemodynamic values, respiratory rate, and shivering was seen in the active core-rewarming group when compared with the controls. The temporal course of shivering was different from those of body temperatue and BI. The control patients showed a significant increase in the serum-potassium levels, which were not seen in the active-core rewarming group. Conclusions The BI analysis changed as a function of the changes of core temperature and independently of the shivering. In addition, our results support the beneficial use of active core rewarming to prevent accidental hypothermia.
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Affiliation(s)
- Alma Rebeca Gutiérrez-Cruz
- Laboratorio de Medicina Genómica, Hospital Regional "Primero de Octubre", Av, IPN, No, 1669, Mexico, D, F,, C,P, 07760, Mexico.
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Szokoly M, Nemeth N, Furka I, Miko I. Hematological and hemostaseological alterations after warm and cold limb ischemia-reperfusion in a canine model. Acta Cir Bras 2010; 24:338-46. [PMID: 19851685 DOI: 10.1590/s0102-86502009000500002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 06/16/2009] [Indexed: 11/03/2023] Open
Abstract
PURPOSE Acute ischemia-reperfusion (I/R) of extremities means serious challenge in the clinical practice. Furthermore, the issue of preventive cooling is still controversial. In this canine model we investigated whether limb I/R -with or without cooling- has an influence on hematological and hemostaseological factors. METHODS Femoral vessels were exposed and clamped for 3 hours. After release the clamps, 4-hour reperfusion was secured. The same procedures with cooling using ice bags, as well as warm and cold sham-operations were performed. Before operations, from the excluded limb by the end of ischemia, during the reperfusion, and for 5 postoperative days afterwards blood samples were collected for testing hematological and blood coagulation parameters. RESULTS After I/R activated partial thromboplastin time was elongated on 2nd-4th postoperative days. The highest values were on the 2nd day in cold I/R group, accompanied by increased prothrombin time values. The hematological parameters and fibrinogen level showed non-specific changes. In excluded ischemic limb the blood composition showed controversial data. Cold ischemia induced larger alterations, however platelet count, hematocrit changed more expressly in warm ischemia. CONCLUSION These results indicate the risk of coagulopathy following limb I/R on early post-eventually days, which risk is higher in the case of cold I/R.
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Thompson HJ, Kirkness CJ, Mitchell PH. Hypothermia and rapid rewarming is associated with worse outcome following traumatic brain injury. J Trauma Nurs 2010; 17:173-7. [PMID: 21157248 PMCID: PMC3556902 DOI: 10.1097/jtn.0b013e3181ff272e] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of the present study was to determine (1) the prevalence and degree of hypothermia in patients on emergency department admission and (2) the effect of hypothermia and rate of rewarming on patient outcomes. METHODS Secondary data analysis was conducted on patients admitted to a level I trauma center following severe traumatic brain injury (n = 147). Patients were grouped according to temperature on admission according to hypothermia status and rate of rewarming (rapid or slow). Regression analyses were performed. FINDINGS Hypothermic patients were more likely to have lower postresuscitation Glasgow Coma Scale scores and a higher initial injury severity score. Hypothermia on admission was correlated with longer intensive care unit stays, a lower Glasgow Coma Scale score at discharge, higher mortality rate, and lower Glasgow outcome score-extended scores up to 6 months postinjury (P < .05). When controlling for other factors, rewarming rates more than 0.25°C/h were associated with lower Glasgow Coma Scale scores at discharge, longer intensive care unit length of stay, and higher mortality rate than patients rewarmed more slowly although these did not reach statistical significance. CONCLUSION Hypothermia on admission is correlated with worse outcomes in brain-injured patients. Patients with traumatic brain injury who are rapidly rewarmed may be more likely to have worse outcomes. Trauma protocols may need to be reexamined to include controlled rewarming at rates 0.25°C/h or less.
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Affiliation(s)
- Hilaire J Thompson
- Biobehavioral Nursing and Health Systems, University of Washington, Seattle, Washington, USA.
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Abstract
Damage control surgery, initially formalized <20 yrs ago, was developed to overcome the poor outcomes in exsanguinating abdominal trauma with traditional surgical approaches. The core concepts for damage control of hemorrhage and contamination control with abbreviated laparotomy followed by resuscitation before definitive repair, although simple in nature, have led to an alteration in which emergent surgery is handled among a multitude of problems, including abdominal sepsis and battlefield surgery. With the aggressive resuscitation associated with damage control surgery, understanding of abdominal compartment syndrome has expanded. It is probably through avoiding this clinical entity that the greatest improvement in surgical outcomes for various emergent surgical problems has occurred in the past two decades. However, with its success, new problems have emerged, including increases in enterocutaneous fistulas and open abdomens. But as with any crisis, innovative strategies are being developed. New approaches to control of the open abdomen and reconstruction of the abdominal wall are being developed from negative pressure dressing therapies to acellular allograft meshes. With further understanding of new resuscitative strategies, the need for damage control surgery may decline, along with its concomitant complications, at the same time retaining the success that damage control surgery has brought to the critically ill trauma and general surgery patient in the past few years.
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Ding Y, Gao ZG, Jacobson KA, Suffredini AF. Dexamethasone enhances ATP-induced inflammatory responses in endothelial cells. J Pharmacol Exp Ther 2010; 335:693-702. [PMID: 20826566 DOI: 10.1124/jpet.110.171975] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The purinergic nucleotide ATP is released from stressed cells and is implicated in vascular inflammation. Glucocorticoids are essential to stress responses and are used therapeutically, yet little information is available that describes the effects of glucocorticoids on ATP-induced inflammation. In a human microvascular endothelial cell line, extracellular ATP-induced interleukin (IL)-6 secretion in a dose- and time-dependent manner. When cells were pretreated with dexamethasone, a prototypic glucocorticoid, ATP-induced IL-6 production was enhanced in a time- and dose-dependent manner. Mifepristone, a glucocorticoid receptor antagonist, blocked these effects. ATP-induced IL-6 release was significantly inhibited by a phospholipase C inhibitor [1-[6-[((17β)-3-methoxyestra-1,3,5[10]-trien-17-yl)amino]hexyl]-1H-pyrrole-2,5-dione (U73122)] (63.2 ± 3%, p < 0.001) and abolished by a p38 mitogen-activated protein kinase inhibitor [4-(4-fluorophenyl)-2-(4-methylsulfinylphenyl)-5-(4-pyridyl)-1H-imidazole (SB 203580)] (88 ± 1%, p < 0.001). Cells treated with dexamethasone induced mRNA expression of the purinergic P2Y(2) receptor (P2Y(2)R) 1.8- ± 0.1-fold and, when stimulated with ATP, enhanced Ca(2+) release and augmented IL-6 mRNA expression. Silencing of the P2Y(2)R by its small interfering RNA decreased ATP-induced IL-6 production by 81 ± 1% (p < 0.001). Dexamethasone enhanced the transcription rate of P2Y(2)R mRNA and induced a dose-related increase in the activity of the P2Y(2)R promoter. Furthermore, dexamethasone-enhanced ATP induction of adhesion molecule transcription and augmented the release of IL-8. Dexamethasone leads to an unanticipated enhancement of endothelial inflammatory mediator production by extracellular ATP via a P2Y(2)R-dependent mechanism. These data define a novel positive feedback loop of glucocorticoids and ATP-induced endothelial inflammation.
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Affiliation(s)
- Yi Ding
- Critical Care Medicine Department, Clinical Center and Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institutes of Health, Bethesda, Maryland 20892-1662, USA
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Finkelstein RA, Alam HB. Induced hypothermia for trauma: current research and practice. J Intensive Care Med 2010; 25:205-26. [PMID: 20444735 DOI: 10.1177/0885066610366919] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Induction of hypothermia with the goal of providing therapeutic benefit has been accepted for use in the clinical setting of adult cardiac arrest and neonatal hypoxic-ischemic encephalopathy (HIE). However, its potential as a treatment in trauma is not as well defined. This review discusses potential benefits and complications of induced hypothermia (IH) with emphasis on the current state of knowledge and practice in various types of trauma. There is excellent preclinical research showing that in cases of penetrating trauma with cardiac arrest, inducing hypothermia to 10 degrees C using cardiopulmonary bypass (CPB) could possibly save those otherwise likely to die without causing neurologic sequelae. A human trial of this intervention is about to get underway. Preclinical studies suggest that inducing hypothermia may be useful to delay cardiac arrest in penetrating trauma victims who are hypotensive. There is potential for IH to be used in cases of blunt trauma, but it has not been well studied. In the case of traumatic brain injury (TBI), clinical trials have shown conflicting results, despite almost uniform efficacy seen in preclinical experiments. Major studies are analyzed and ways to standardize its use and optimize future clinical trials are discussed. More preclinical and clinical research is needed to better define whether there could be a role for IH in the case of spinal cord injuries.
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Affiliation(s)
- Robert A Finkelstein
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
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Abstract
Multiple trauma patients frequently demonstrate a hypothermic core temperature, defined as a temperature below 35 degrees C, already at admission in the emergency room. As a drop of the core temperature below 34 degrees C has been shown to be associated with a significant increase in post-traumatic complications, this limit is considered to be critical in these patients. Multiple trauma patients with hypothermia demonstrate a markedly increased mortality rate compared to normothermic patients with the same injury severity. Therefore effective rewarming measures are essential for adequate bleeding control and successful resuscitation. If and to what extent the induction of controlled hypothermia in the early phase of treatment on the intensive care unit after resuscitation and operative bleeding control can contribute to an improved post-traumatic outcome, has to be clarified in further experimental and clinical studies.
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Abstract
Pathophysiology of multiple trauma is characterized by different trauma-associated repercussions like organ destruction, haemorrhage, immune cell activation by foreign antigen, for example. The length of time while such impairments take hold of the organism substantially impacts the extent of the post trauma secondary injury. Short interruptions in microcirculation can mostly be compensated, whereas elongated ischemic periods definitely cause structural cell damage up to death. The current review highlights the importance of the time duration of posttrauma second hits on the pathophysiology of systemic inflammation and multiple organ failure. The quick termination of such secondary impairments by immediate therapeutic intervention mainly impacts the patients' prognosis.
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Hypothermia is associated with improved outcomes in a porcine model of hemorrhagic shock. ACTA ACUST UNITED AC 2010; 68:662-8. [PMID: 20220422 DOI: 10.1097/ta.0b013e3181d3cbc0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND : Hypothermia after trauma is, in current medical practice, both avoided and aggressively treated. However, the effects of environmental hypothermia during early resuscitation after hemorrhagic shock have been only poorly characterized. METHODS : The objective of our study was to compare normothermia versus mild and severe levels of hypothermia in a porcine model of hemorrhagic shock. In a prospective survival study, we anesthetized 19 juvenile male pigs (Yorkshire-Landrace, 15-25 kg) and caused them to hemorrhage until their systolic blood pressure was 45 mm Hg to 55 mm Hg for a duration of 45 minutes. Then, we randomized them into three groups (all of which underwent an 8-hour limited resuscitation period) as follows: normothermic (39 degrees C), mildly hypothermic (36 degrees C), and severely hypothermic (33 degrees C). We used ice packs to achieve surface cooling that mimicked environmental hypothermia. After 8 hours, we rewarmed the pigs and fully resuscitated them for 16 hours. We extubated the survivors and observed them for an additional 24 hours, before killing them. RESULTS : Surface cooling resulted in significant reduction in core body temperature. The mortality rate was significantly higher in the normothermic group (60%) than in the two hypothermic groups combined (7%) (p = 0.015) or in the severely hypothermic group (0%) (p = 0.023). Hypothermic animals had significantly lower levels of creatinine kinase, lactate dehydrogenase, and lactate in addition to a lower base deficit after shock. However, severely hypothermic animals required greater volumes of colloid infusion and whole blood transfusion to maintain our target systolic blood pressure and hemoglobin levels when compared with normothermic animals. We saw a strong trend toward decreased oxygen consumption with hypothermia. CONCLUSIONS : In our porcine model, we found that simulating mild and severe levels of environmental hypothermia during early resuscitation after hemorrhage was associated with a significantly decreased mortality rate. Furthermore, markers of cellular stress and organ dysfunction, including lactate levels and the base deficit, were lower in hypothermic animals. Decreasing oxygen consumption with hypothermia may, in part, explain the protective effects observed with hypothermia.
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Abstract
OBJECTIVE Hypothermia is an independent predictor of mortality in adult trauma studies. However, the impact of hypothermia on the pediatric trauma population has not been described. The purpose of this study is to evaluate hypothermia as a cofactor to mortality, complications, and among survivors, hospital length of stay parameters in the pediatric trauma population. DESIGN Retrospective review of a prospectively collected database (National Trauma Registry of the American College of Surgeons) over a 5-yr period (July 2002 to June 2007). SETTING A rural, level I trauma center. PATIENTS One thousand six hundred twenty-nine pediatric patients admitted with a traumatic injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Multivariate regression models were used to evaluate the association of hypothermia with mortality, infectious complications, organ dysfunction, and among survivors, hospital length of stay parameters. Of 1,629 pediatric trauma patients admitted, 182 (11.1%) patients were hypothermic (temperature below 36 degrees C) on admission. Hypothermia had an adjusted odds ratio (AOR) of 2.41 (95% confidence interval [CI], 1.12-5.22, p = .025) for mortality. After controlling for covariates, hypothermia had associations with developing pneumonia (AOR, 0.185, 95% CI, 0.040-0.853; p = .031) and a bleeding diathesis (AOR, 3.14, 95% CI, 1.04-9.44; p = .042). The median days in the hospital, intensive care unit (ICU), and ventilator were longer in the hypothermic cohort; however, after controlling for covariates, hypothermia was not associated with differences in hospital days, ICU days, or ventilator days. CONCLUSIONS Hypothermia is a common problem at admission among pediatric trauma patients. Hypothermia is associated with an increase in the odds of death and the development of a bleeding diathesis, while having decreased odds for developing pneumonia. While the length of stay indicators were longer in the hypothermic cohort among survivors, no significant association was noted with hypothermia for hospital, ICU, or ventilator days after controlling for confounders.
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Kheirbek T, Kochanek AR, Alam HB. Hypothermia in bleeding trauma: a friend or a foe? Scand J Trauma Resusc Emerg Med 2009; 17:65. [PMID: 20030810 PMCID: PMC2806855 DOI: 10.1186/1757-7241-17-65] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 12/23/2009] [Indexed: 11/10/2022] Open
Abstract
The induction of hypothermia for cellular protection is well established in several clinical settings. Its role in trauma patients, however, is controversial. This review discusses the benefits and complications of induced hypothermia--emphasizing the current state of knowledge and potential applications in bleeding patients. Extensive pre-clinical data suggest that in advanced stages of shock, rapid cooling can protect cells during ischemia and reperfusion, decrease organ damage, and improve survival. Yet hypothermia is a double edged sword; unless carefully managed, its induction can be associated with a number of complications. Appropriate patient selection requires a thorough understanding of the pre-clinical literature. Clinicians must also appreciate the enormous influence that temperature modulation exerts on various cellular mechanisms. This manuscript aims to provide a balanced view of the published literature on this topic. While many of the advantageous molecular and physiological effects of induced hypothermia have been outlined in animal models, rigorous clinical investigations are needed to translate these promising findings into clinical practice.
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Affiliation(s)
- Tareq Kheirbek
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
- Department of Surgery, Washington Hospital Center, Washington, DC, USA
| | - Ashley R Kochanek
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Hasan B Alam
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
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Impact of hypothermia (below 36 degrees C) in the rural trauma patient. J Am Coll Surg 2009; 209:580-8. [PMID: 19854397 DOI: 10.1016/j.jamcollsurg.2009.07.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 07/12/2009] [Accepted: 07/28/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hypothermia is an independent predictor of mortality based on urban studies. But this association has not been described in the rural setting. This study's purpose was to evaluate hypothermia as a cofactor to mortality, complications, and hospital length of stay (LOS) parameters in the rural trauma setting. STUDY DESIGN The National Trauma Registry of the American College of Surgeons database for our rural, Level I trauma center was queried for a 5-year period (July 2002 to June 2007) to identify adult trauma patients. Multivariate regression models were used to evaluate the association of hypothermia with mortality; infectious complications; organ dysfunction; and, among survivors, hospital LOS parameters. RESULTS Of 9,482 adult patients admitted, 1,490 (15.7%) patients were hypothermic. Hypothermia had an adjusted odds ratio of 1.70 for mortality (95% CI, 1.35 to 2.12; p < 0.001). After controlling for covariates, hypothermia was not significantly associated with infectious complications or organ dysfunction, except for arrhythmia (adjusted odds ratio, 1.40; CI, 1.03 to 1.90; p = 0.031). Hypothermia was not associated with a difference in ICU (p = 0.310) or ventilator (p = 0.144) LOS. But a slight increase in hospital days was noted in the hypothermic patient (hazards ratio, 0.890 for discharge; 95% CI, 0.838 to 0.946; p < 0.001). CONCLUSIONS Hypothermia is a common problem at admission in a rural trauma center. It is associated with an increase in hospitalized days but not with increased ICU or ventilator days among survivors. Other than arrhythmias, it was not significantly associated with other National Trauma Registry of the American College of Surgeons infectious or organ dysfunction complications. Hypothermia is an independent risk factor for mortality in the rural trauma patient.
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Schmidt C, Moritz S, Rath S, Grossmann E, Wiesenack C, Piso P, Graf BM, Bucher M. Perioperative management of patients with cytoreductive surgery for peritoneal carcinomatosis. J Surg Oncol 2009; 100:297-301. [PMID: 19697426 DOI: 10.1002/jso.21322] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an important tool in the management of patients with peritoneal malignancies. It is a complex surgical procedure with significant fluid loss during debulking leading to relevant pathophysiological alterations and therefore a challenge for anesthesiologists and critical care physicians. This review summarizes perioperative changes in hemodynamics, oxygen supply, coagulation, hematopoetic parameters and fluid status during cytoreductive surgery and HIPEC and how to deal with these pathophysiological alterations.
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Affiliation(s)
- C Schmidt
- Department of Anesthesiology, University of Regensburg, Regensburg, Germany.
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Abstract
Exsanguinating hemorrhage is a common clinical feature of multisystem trauma that results in death or severe disability. Cardiovascular collapse resulting from hemorrhage is unresponsive to conventional methods of cardiopulmonary resuscitation. Even when bleeding is controlled rapidly, adequate circulation cannot be restored in time to avoid neurologic consequences that appear after only 5 mins of cerebral ischemia and hypoperfusion. Reperfusion adds further insult to injury. A novel solution to this problem would be to institute a therapy that makes cells and organs more resistant to ischemic injury, thereby extending the time they can tolerate such an insult. Hypothermia can attenuate some effects of ischemia and reperfusion. Accumulating preclinical data demonstrate that hypothermia can be induced safely and rapidly to achieve emergency preservation for resuscitation during lethal hemorrhage. Hypothermia may be an effective therapeutic approach for otherwise lethal traumatic hemorrhage, and a clinical trial to determine its utility is warranted.
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Early Hypothermia in Severely Injured Trauma Patients Is a Significant Risk Factor for Multiple Organ Dysfunction Syndrome but Not Mortality. Ann Surg 2009; 249:845-50. [DOI: 10.1097/sla.0b013e3181a41f6f] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Mirzayan MJ, Probst C, Krettek C, Samii M, Pape HC, van Griensven M, Samii A. Systemic effects of isolated brain injury: an experimental animal study. Neurol Res 2008; 30:457-460. [DOI: 10.1179/174313208x276907] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Sailhamer EA, Chen Z, Ahuja N, Velmahos GC, de Moya M, Rhee P, Shults C, Alam HB. Profound hypothermic cardiopulmonary bypass facilitates survival without a high complication rate in a swine model of complex vascular, splenic, and colon injuries. J Am Coll Surg 2007; 204:642-53. [PMID: 17382224 DOI: 10.1016/j.jamcollsurg.2007.01.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Revised: 12/08/2006] [Accepted: 01/08/2007] [Indexed: 11/16/2022]
Abstract
BACKGROUND Induction of a profound hypothermia for emergency preservation and resuscitation in severe hemorrhagic shock can improve survival from lethal injuries, but the impact of hypothermia on bleeding and infectious complications has not been completely determined. STUDY DESIGN Uncontrolled hemorrhage was induced in 26 swine (95 to 135 lbs) by creating an iliac artery and vein injury, and 30 minutes later, by lacerating the descending thoracic aorta. Through a left thoracotomy approach, profound total body hypothermia (10 degrees C) was induced (2 degrees C/min) by infusing cold organ preservation solution into the aorta. The experimental groups were: vascular injuries alone (group 1, n=10), vascular and colon injuries (group 2, n=8), and vascular, colon, and splenic injuries (group 3, n=8). All injuries were repaired during 60 minutes of low-flow cardiopulmonary bypass (CPB) with hemodilution and profound hypothermia; then the animals were slowly rewarmed (0.5 degrees C/min) back to normothermia. Survivors were monitored for 6 weeks for postoperative bleeding, neurologic deficits, cognitive function (learning new skills), organ dysfunction, and septic complications. RESULTS Six-week survival rates were 90% in group 1, 87.5% in group 2, and 75% in group 3 (p > 0.05). One animal in each group died from acute cardiac failure during the early postoperative phase. Splenic salvage was possible in all animals, and none required complete splenectomy for hemorrhage control. All surviving animals were neurologically intact, displayed normal learning capacity, and had no longterm organ dysfunction. None of the animals had postoperative hemorrhage or experienced septic complications. One animal in group 3 died on the ninth postoperative day because of bowel obstruction (volvulus). CONCLUSIONS Induction of profound hypothermia can preserve the viability of key organs during repair of lethal injuries. This strategy can be used even in the presence of solid organ and bowel injuries to improve survival, without any considerable increase in postoperative complication rates.
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Affiliation(s)
- Elizabeth A Sailhamer
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
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Alam HB, Chen Z, Li Y, Velmahos G, DeMoya M, Keller CE, Toruno K, Mehrani T, Rhee P, Spaniolas K. Profound hypothermia is superior to ultraprofound hypothermia in improving survival in a swine model of lethal injuries. Surgery 2006; 140:307-14. [PMID: 16904984 DOI: 10.1016/j.surg.2006.03.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Revised: 03/23/2006] [Accepted: 03/27/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Rapid induction of profound hypothermia can improve survival from uncontrolled lethal hemorrhage. However, the optimal depth of hypothermia in this setting remains unknown. This experiment was designed to compare the impact of deep (15 degrees C), profound (10 degrees C), and ultraprofound (5 degrees C) hypothermia on survival and organ functions. METHODS Uncontrolled lethal hemorrhage was induced in 32 swine (80-120 lb) by creating an iliac artery and vein injury, followed 30 minutes later by laceration of the descending thoracic aorta. Hypothermia was induced rapidly (2 degrees C/min) by infusing cold organ preservation solution into the aorta through a thoracotomy. The experimental groups were (n = 8 per group): a normothermic control, and 3 hypothermic groups in which the core temperature was reduced to 15 degrees C, 10 degrees C, and 5 degrees C. Vascular injuries were repaired during 60 minutes of hypothermia. Animals were then rewarmed (0.5 degrees C/min) and resuscitated on cardiopulmonary bypass, and monitored for 6 weeks for neurologic deficits, cognitive function, and organ dysfunction. RESULTS All normothermic animals died, whereas 6-week survival rates for the 15 degrees C, 10 degrees C, and 5 degrees C groups were 62.5%, 87.5%, and 25%, respectively (P < .05: normothermic vs 15 degrees C and 10 degrees C; 10 degrees C vs 5 degrees C). The surviving animals from the 15 degrees C and 10 degrees C groups were neurologically intact, displayed normal learning capacity, and had no long-term organ dysfunction. The survivors from the 5 degrees C group displayed slower recovery and impaired cognitive functions. CONCLUSIONS In a model of lethal injuries, rapid induction of profound hypothermia can prevent death. The depth of hypothermia influences survival, with a better outcome associated with a core temperature of 10 degrees C compared with 5 degrees C.
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MESH Headings
- Animals
- Body Temperature
- Brain/pathology
- Brain/physiopathology
- Circulatory Arrest, Deep Hypothermia Induced/adverse effects
- Circulatory Arrest, Deep Hypothermia Induced/methods
- Circulatory Arrest, Deep Hypothermia Induced/psychology
- Cognition/physiology
- Disease Models, Animal
- Female
- Shock, Hemorrhagic/pathology
- Shock, Hemorrhagic/psychology
- Shock, Hemorrhagic/therapy
- Swine
- Wounds, Penetrating/pathology
- Wounds, Penetrating/psychology
- Wounds, Penetrating/therapy
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Affiliation(s)
- Hasan B Alam
- Trauma Research and Readiness Institute for Surgery, Uniformed Services University of the Health Sciences, Bethesda, USA
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Alam HB, Rhee P, Honma K, Chen H, Ayuste EC, Lin T, Toruno K, Mehrani T, Engel C, Chen Z. Does the Rate of Rewarming from Profound Hypothermic Arrest Influence the Outcome in a Swine Model of Lethal Hemorrhage? ACTA ACUST UNITED AC 2006; 60:134-46. [PMID: 16456447 DOI: 10.1097/01.ta.0000198469.95292.ec] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Rapid induction of profound hypothermic arrest (suspended animation) can provide valuable time for the repair of complex injuries and improve survival. The optimal rate for re-warming from a state of profound hypothermia is unknown. This experiment was designed to test the impact of different warming rates on outcome in a swine model of lethal hemorrhage from complex vascular injuries. METHODS Uncontrolled lethal hemorrhage was induced in 40 swine (80-120 lbs) by creating an iliac artery and vein injury, followed 30 minutes later (simulating transport time) by laceration of the descending thoracic aorta. Through a thoracotomy approach, a catheter was placed in the aorta and hyperkalemic organ preservation solution was infused on cardiopulmonary bypass to rapidly (2 degrees C/min) induce profound (10 degrees C) hypothermia. Vascular injuries were repaired during 60 minutes of hypothermic arrest. The 4 groups (n = 10/group) included normothermic controls (NC) where core temperature was maintained between 36 to 37 degrees C, and re-warming from profound hypothermia at rates of: 0.25 degrees C/min (slow), 0.5 degrees C/min (medium), or 1 degrees C/min (fast). Hyperkalemia was reversed during the hypothermic arrest period, and blood was infused for resuscitation during re-warming. After discontinuation of cardiopulmonary bypass, the animals were recovered and monitored for 6 weeks for neurologic deficits, cognitive function (learning new skills), and organ dysfunction. Detailed examination of brains was performed at 6 weeks. RESULTS All the normothermic animals died, whereas survival rates for slow, medium and fast re-warming from hypothermic arrest were 50, 90, and 30%, respectively (p < 0.05 slow and medium warming versus normothermic control, p < 0.05 medium versus fast re-warming). All the surviving animals were neurologically intact, displayed normal learning capacity, and had no long-term organ dysfunction. CONCLUSIONS Rapid induction of hypothermic arrest maintains viability of brain during repair of lethal vascular injuries. Long-term survival is influenced by the rate of reversal of hypothermia.
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Affiliation(s)
- Hasan B Alam
- Trauma Research and Readiness Institute for Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Shafi S, Elliott AC, Gentilello L. Is Hypothermia Simply a Marker of Shock and Injury Severity or an Independent Risk Factor for Mortality in Trauma Patients? Analysis of a Large National Trauma Registry. ACTA ACUST UNITED AC 2005; 59:1081-5. [PMID: 16385283 DOI: 10.1097/01.ta.0000188647.03665.fd] [Citation(s) in RCA: 126] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Successful application of induced hypothermia (HT) after stroke and cardiac arrest has led to a resurgence of interest in its potential protective effects in trauma patients. Although clinical studies demonstrate an adverse effect, they consist of small studies from single institutions. We tested the hypothesis that HT is associated with improved survival in trauma patients by analyzing a large, national trauma database. METHODS The study included all patients in the National Trauma Data Bank (1994-2002) aged 18 to 55 years old with temperature at presentation to the emergency department and base deficit (BD) recorded. Hypothermic (temperature, <35 degrees C; n = 3267) patients and patients with normothermia (temperature, > or =35 degrees C; n = 35,283) patients were compared. Two analyses were conducted to control for the association between HT and injury severity. First, hypothermic and normothermic (NT) patients were stratified by injury severity score (ISS) and shock (blood pressure < or = 90 mm Hg). Next, logistic regression was used to control for effects of age, sex, mechanism, ISS, head, chest, and abdominal injuries, BP, Glasgow Coma Scale score, and BD, with survival as the dependent and HT as the predictor variable. RESULTS Although HT was more common in more seriously injured patients, stratified analysis revealed that hypothermic patients have significantly higher mortality than patients with the same severity of injury who remain NT. Even after controlling for injury severity and the other potential confounders listed above, HT remained a strong, independent predictor of mortality (odds ratio, 1.19; 95% confidence interval, 1.05-1.35). CONCLUSION There is no apparent protective effect of HT in trauma patients. HT itself, not just its association with shock, injury severity, and other cofactors lead to a significant increase in mortality in injured patients. Continued, aggressive efforts to prevent and treat HT are warranted.
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Affiliation(s)
- Shahid Shafi
- Department of Surgery, Division of Burn, Trauma and Surgical Critical Care, University of Texas Southwestern Medical School, Dallas, Texas 75390-9158, USA.
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Martin RS, Kilgo PD, Miller PR, Hoth JJ, Meredith JW, Chang MC. Injury-associated hypothermia: an analysis of the 2004 National Trauma Data Bank. Shock 2005; 24:114-8. [PMID: 16044080 DOI: 10.1097/01.shk.0000169726.25189.b1] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Severe injury and shock are frequently associated with abnormalities in patient body temperature. Substantial increases in mortality have been associated with profound hypothermia, especially below 35 degrees C. The purpose of this study was to further characterize the impact of hypothermia in a large dataset of trauma patients. This study was a retrospective analysis of the 2004 version of the National Trauma Data Bank (NTDB), which contains approximately 1.1 million patients from over 400 trauma centers. Admission temperature was analyzed with respect to mortality, injury severity score (ISS), base deficit (BD), Glasgow Coma Score (GCS), and hospital outcomes. The NTDB contained 701,491 patients with temperatures recorded upon trauma center admission. Of these, 11,026 patients had admission temperatures <35 degrees C, and 802 had temperatures <32 degrees C. Comparison of core temperature versus mortality revealed that as temperature decreased, the mortality rate increased, reaching approximately 39% at 32 degrees C, and remained constant at lower temperatures. Surprisingly, 477 patients (59.5%) survived with temperatures <32 degrees C. Similarly, BD increased as hypothermia worsened until body temperature reached 31 degrees C, below which there was little further increase. Patients with admission temperatures less than 35 degrees C had significantly greater mortality (25.5% vs. 3.0%, P < 0.001) and BD (7.8 vs. 3.7, P < 0.001) when compared with patients with temperatures >or=35 degrees C. In survivors, average ventilator days and intensive care unit (ICU) days were 14.4 and 12.8, respectively, for patients with temperatures <35 degrees C as opposed to more normothermic patients who demonstrated an average of 9.5 ventilator days and 9.1 ICU days (P < 0.001). When grouped by individual ISS, BD level, and GCS motor score, mortality was significantly greater when admission temperature was below 35 degrees C (ISS mean difference = 11.4%, BD mean difference = 22.8%, and GCS motor mean difference = 9.85%). Logistic regression revealed that hypothermia remains an independent determinant of mortality after correction for confounding variables (odds ratio = 1.54, 95% confidence interval 1.40-1.71). Admission hypothermia is associated with greater mortality, increased injury severity, more profound acidosis, and prolonged ICU/ventilator courses. However, although mortality at <32 degrees C is high, patients with temperatures this low do survive. As temperatures drop below 32 degrees C, mortality rates remain constant, which may indicate a threshold below which physiologic mechanisms are unable to correct body temperature regardless of injury severity. Although shock severity is highly indicative of outcome, hypothermia independently contributes to the substantial mortality associated with severe injury.
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Affiliation(s)
- R Shayn Martin
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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45
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Alam HB, Chen Z, Honma K, Koustova E, Querol RILC, Jaskille A, Inocencio R, Ariaban N, Toruno K, Nadel A, Rhee P. The rate of induction of hypothermic arrest determines the outcome in a Swine model of lethal hemorrhage. ACTA ACUST UNITED AC 2005; 57:961-9. [PMID: 15580018 DOI: 10.1097/01.ta.0000149549.72389.3f] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lethal injuries can be surgically repaired under asanguineous hypothermic condition (suspended animation) with excellent outcome. However, the optimal rate for the induction of hypothermic metabolic arrest following uncontrolled lethal hemorrhage (ULH) is unknown. METHODS ULH was induced in 32 female swine (80-120 lbs) by creating an iliac artery and vein injury, followed 30 minutes later by laceration of the descending thoracic aorta. Through a left thoracotomy approach, total body hypothermic hyperkalemic metabolic arrest was induced by infusing organ preservation fluids into the aorta. Experimental groups were: normothermic controls (no cooling, NC), or hypothermia induced at a rate of 0.5 degrees C/min (slow, SC), 1 degrees C/min (medium, MC), or 2 degrees C/min (fast, FC). Vascular injuries were repaired during the 60 minutes of profound (10 degrees C) hypothermic arrest. Hyperkalemia was reversed by hypokalemic fluid exchange, and blood was infused for resuscitation during the re-warming (0.5 degrees C/ minute) period. The survivors were monitored for 6 weeks. RESULTS The 6 week survival rates were 0% (NC), 37.5% (SC), 62.5% (MC), and 87.5% (FC) respectively (p < 0.05 MC&FC versus NC). All of the surviving hypothermic arrest animals were neurologically intact and displayed no long term organ dysfunction. CONCLUSION Hypothermic metabolic arrest can be used to maintain viability of key organs during repair of lethal injuries. Survival is influenced by the rate of cooling with the best outcome following rapid induction of hypothermia.
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Affiliation(s)
- Hasan B Alam
- Trauma Research and Readiness Institute for Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814, USA.
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Yang X, Hachimi-Idrissi S, Nguyen DN, Zizi M, Huyghens L. Effect of resuscitative mild hypothermia and oxygen concentration on the survival time during lethal uncontrolled haemorrhagic shock in mechanically ventilated rats. Eur J Emerg Med 2004; 11:210-6. [PMID: 15249808 DOI: 10.1097/01.mej.0000136695.72213.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To test the hypothesis that resuscitative mild hypothermia (MH) (34 degrees C) or breathing fractional inspired oxygen (FIo2) of 1.0 would prolong survival time during lethal uncontrolled haemorrhagic shock (UHS) in mechanically ventilated rats. METHODS Forty Wistar rats were anaesthetized with halothane, nitrous oxide and oxygen (70/30%), intubated and mechanically ventilated. UHS was induced by volume-controlled blood withdrawal of 3 ml/100 g over 15 min, followed by 75% tail amputation of its length. The animals were randomly divided into four UHS treatment groups (10 rats in each group): group 1 was maintained on an FIo2 of 0.21 and rectal temperature of 37.5 degrees C. Group 2 was maintained on an FIo2 of 0.21 and induced MH. Group 3 was maintained on an FIo2 of 1.0 and 37.5 degrees C. Group 4 was maintained on an FIo2 of 1.0 and MH. Rats were observed otherwise untreated until death. RESULTS During the initial blood withdrawal, mean arterial pressure (MAP) decreased to 40 mmHg, and the heart rate (HR) increased up to 400 beats/min. The induction of MH increased MAP to 60 mmHg and increased survival time. Moreover, it reduced the HR to 300 beats/min but did not increase bleeding. Ventilation with an FIo2 of 1.0 did not influence MAP, blood loss or survival time, but increased arterial oxygen tension. The mean survival time was 62, 202, 68 and 209 min in groups 1, 2, 3 and 4, respectively. Blood loss from the tail was 1.0, 1.2, 0.9 and 0.7 ml, respectively, in groups 1, 2, 3 and 4. CONCLUSION MH prolonged the survival time during UHS in mechanically ventilated rats. However, an FIo2 of 1.0 did not influence the survival time or blood loss from the tail.
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Affiliation(s)
- Xin Yang
- Department of Critical Care Medicine and Cerebral Resuscitation Research Group, AZ-VUB, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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Hildebrand F, Giannoudis PV, van Griensven M, Chawda M, Pape HC. Pathophysiologic changes and effects of hypothermia on outcome in elective surgery and trauma patients. Am J Surg 2004; 187:363-71. [PMID: 15006564 DOI: 10.1016/j.amjsurg.2003.12.016] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2002] [Revised: 06/01/2003] [Indexed: 11/17/2022]
Abstract
Generally, hypothermia is defined as a core temperature <35 degrees C. In elective surgery, induced hypothermia has beneficial effects. It is recommended to diminish complications attributable to ischemia reperfusion injury. Experimental studies have shown that hypothermia during hemorrhagic shock has beneficial effects on outcome. In contrast, clinical experience with hypothermia in trauma patients has shown accidental hypothermia to be a cause of posttraumatic complications. The different etiology of hypothermia might be one reason for this disparity because induced therapeutic hypothermia, with induction of poikilothermia and shivering prevention, is quite different from accidental hypothermia, which results in physiological stress. Other studies have shown evidence that this contradictory effect is related to the plasma concentration of high-energy phosphates (e.g., adenosine triphosphate [ATP]). Induced hypothermia preserves ATP storage, whereas accidental hypothermia causes depletion. Hypothermia also has an impact on the immunologic response after trauma and elective surgery by decreasing the inflammatory response. This might have a beneficial effect on outcome. Nevertheless, posttraumatic infectious complications may be higher because of an immunosuppressive profile. Further studies are needed to investigate the impact of induced hypothermia on outcome in trauma patients.
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Affiliation(s)
- Frank Hildebrand
- Trauma Department, Medical School Hanover, Carl-Neuberg-Strasse 1, 30625 Hanover, Germany.
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48
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Abstract
BACKGROUND Clinical trials of induced hypothermia have suggested that this treatment may be beneficial in selected patients with neurologic injury. OBJECTIVES To review the topic of induced hypothermia as a treatment of patients with neurologic and other disorders. DESIGN Review article. INTERVENTIONS None. MAIN RESULTS Improved outcome was demonstrated in two prospective, randomized, controlled trials in which induced hypothermia (33 degrees C for 12-24 hrs) was used in patients with anoxic brain injury following resuscitation from prehospital cardiac arrest. In addition, prospective, randomized, controlled trials have been conducted in patients with severe head injury, with variable results. There also have been preliminary clinical studies of induced hypothermia in patients with severe stroke, newborn hypoxic-ischemic encephalopathy, neurologic infection, and hepatic encephalopathy, with promising results. Finally, animal models have suggested that hypothermia that is induced rapidly following traumatic cardiac arrest provides significant neurologic protection and improved survival. CONCLUSIONS Induced hypothermia has a role in selected patients in the intensive care unit. Critical care physicians should be familiar with the physiologic effects, current indications, techniques, and complications of induced hyperthermia.
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Abraham EH, Salikhova AY, Hug EB. Critical ATP parameters associated with blood and mammalian cells: Relevant measurement techniques. Drug Dev Res 2003. [DOI: 10.1002/ddr.10194] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Janczyk RJ, Park DY, Howells GA, Bair HA, Jonik AM, McFall RE, Bendick PJ, Gentilello LM. High-flow venovenous rewarming for the correction of hypothermia in a canine model of hypovolemic shock. THE JOURNAL OF TRAUMA 2002; 53:639-45; discussion 645. [PMID: 12394860 DOI: 10.1097/00005373-200210000-00004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continuous arteriovenous rewarming (CAVR) has been shown to effectively reverse hypothermia; however, its use is limited in the setting of profound hypotension. We have evaluated the effectiveness of high-flow venovenous rewarming (HFVR) using bypass for the correction of hypothermia in a hypotensive canine model and compared these results to CAVR. METHODS Eight dogs, randomly assigned to either HFVR or CAVR, were cooled to a core temperature of 29.5 degrees C and then bled to a mean arterial pressure of 55 mm Hg. Rewarming was then initiated and the time required for blood, liver parenchyma, and esophageal (core) temperature to reach 36 degrees C was recorded. RESULTS Mean flow rates were 1,536 +/- 667 mL/min for HFVR and 196 +/- 35 mL/min for CAVR (p = 0.007). Time in minutes to rewarm to 36 degrees C for the HFVR versus the CAVR groups, respectively, were as follows: blood, 12 +/- 2 versus 99 +/- 19; liver, 21 +/- 3 versus 102 +/- 16; and esophageal, 25 +/- 6 versus 125 +/- 17 (all < 0.001). CONCLUSION HFVR is an effective method for rapid rewarming in a profoundly hypothermic, hypotensive animal model and may have clinical utility in patients presenting with hypovolemia/hypotension complicated by hypothermia.
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Affiliation(s)
- Randy J Janczyk
- Division of Trauma Surgery, Department of General Surgery, William Beaumont Hospital, Royal Oak, Michigan 48073, USA
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