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Chou TH, Coyle EF. Cardiovascular responses to hot skin at rest and during exercise. Temperature (Austin) 2022; 10:326-357. [PMID: 37554384 PMCID: PMC10405766 DOI: 10.1080/23328940.2022.2109931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/25/2022] [Accepted: 07/30/2022] [Indexed: 10/15/2022] Open
Abstract
Integrative cardiovascular responses to heat stress during endurance exercise depend on various variables, such as thermal stress and exercise intensity. This review addresses how increases in skin temperature alter and challenge the integrative cardiovascular system during upright submaximal endurance exercise, especially when skin is hot (i.e. >38°C). Current evidence suggests that exercise intensity plays a significant role in cardiovascular responses to hot skin during exercise. At rest and during mild intensity exercise, hot skin increases skin blood flow and abolishes cutaneous venous tone, which causes blood pooling in the skin while having little impact on stroke volume and thus cardiac output is increased with an increase in heart rate. When the heart rate is at relatively low levels, small increases in heart rate, skin blood flow, and cutaneous venous volume do not compromise stroke volume, so cardiac output can increase to fulfill the demands for maintaining blood pressure, heat dissipation, and the exercising muscle. On the contrary, during more intense exercise, hot skin does not abolish exercise-induced cutaneous venoconstriction possibly due to high sympathetic nerve activities; thus, it does not cause blood pooling in the skin. However, hot skin reduces stroke volume, which is associated with a decrease in ventricular filling time caused by an increase in heart rate. When the heart rate is high during moderate or intense exercise, even a slight reduction in ventricular filling time lowers stroke volume. Cardiac output is therefore not elevated when skin is hot during moderate intensity exercise.
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Affiliation(s)
- Ting-Heng Chou
- Center for Regenerative Medicine, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Edward F. Coyle
- Department of Kinesiology and Health Education, The University of Texas at Austin, Texas, Tx, USA
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Périard JD, Eijsvogels TMH, Daanen HAM. Exercise under heat stress: thermoregulation, hydration, performance implications, and mitigation strategies. Physiol Rev 2021; 101:1873-1979. [PMID: 33829868 DOI: 10.1152/physrev.00038.2020] [Citation(s) in RCA: 138] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A rise in body core temperature and loss of body water via sweating are natural consequences of prolonged exercise in the heat. This review provides a comprehensive and integrative overview of how the human body responds to exercise under heat stress and the countermeasures that can be adopted to enhance aerobic performance under such environmental conditions. The fundamental concepts and physiological processes associated with thermoregulation and fluid balance are initially described, followed by a summary of methods to determine thermal strain and hydration status. An outline is provided on how exercise-heat stress disrupts these homeostatic processes, leading to hyperthermia, hypohydration, sodium disturbances, and in some cases exertional heat illness. The impact of heat stress on human performance is also examined, including the underlying physiological mechanisms that mediate the impairment of exercise performance. Similarly, the influence of hydration status on performance in the heat and how systemic and peripheral hemodynamic adjustments contribute to fatigue development is elucidated. This review also discusses strategies to mitigate the effects of hyperthermia and hypohydration on exercise performance in the heat by examining the benefits of heat acclimation, cooling strategies, and hyperhydration. Finally, contemporary controversies are summarized and future research directions are provided.
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Affiliation(s)
- Julien D Périard
- University of Canberra Research Institute for Sport and Exercise, Bruce, Australia
| | - Thijs M H Eijsvogels
- Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hein A M Daanen
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Chou TH, Allen JR, Hahn D, Leary BK, Coyle EF. Cardiovascular responses to exercise when increasing skin temperature with narrowing of the core-to-skin temperature gradient. J Appl Physiol (1985) 2018; 125:697-705. [PMID: 29745802 DOI: 10.1152/japplphysiol.00965.2017] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The decline in stroke volume (SV) during exercise in the heat has been attributed to either an increase in cutaneous blood flow (CBF) that reduces venous return or an increase in heart rate (HR) that reduces cardiac filling time. However, the evidence supporting each mechanism arises under experimental conditions with different skin temperatures (Tsk; e.g., ≥38°C vs. ≤36°C, respectively). We systematically studied cardiovascular responses to progressively increased Tsk (32°C-39°C) with narrowing of the core-to-skin gradient during moderate intensity exercise. Eight men cycled at 63 ± 1% peak oxygen consumption for 20-30 min. Tsk was manipulated by having subjects wear a water-perfused suit that covered most of the body and maintained Tsk that was significantly different between trials and averaged 32.4 ± 0.2, 35.5 ± 0.1, 37.5 ± 0.1, and 39.5 ± 0.1°C, respectively. The graded heating of Tsk ultimately produced a graded elevation of esophageal temperature (Tes) at the end of exercise. Incrementally increasing Tsk resulted in a graded increase in HR and a graded decrease in SV. CBF reached a similar average plateau value in all trials when Tes was above ~38°C, independent of Tsk. Tsk had no apparent effect on forearm venous volume (FVV). In conclusion, the CBF and FVV responses suggest no further pooling of blood in the skin when Tsk is increased from 32.4°C to 39.5°C. The decrease in SV during moderate intensity exercise when heating the skin to high levels appears related to an increase in HR and not an increase in CBF. NEW & NOTEWORTHY This study systematically investigated the effect of increasing skin temperature (Tsk) to high levels on cardiovascular responses during moderate intensity exercise. We conclude that the declines in stroke volume were related to the increases in heart rate but not the changes in cutaneous blood flow (CBF) and forearm venous volume (FVV) during moderate intensity exercise when Tsk increased from ~32°C to ~39°C. High Tsk (≥38°C) did not further elevate CBF and FVV compared with lower Tsk during moderate intensity exercise.
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Affiliation(s)
- Ting-Heng Chou
- Human Performance Laboratory, Department of Kinesiology and Health Education, University of Texas at Austin , Austin, Texas
| | - Jakob R Allen
- Human Performance Laboratory, Department of Kinesiology and Health Education, University of Texas at Austin , Austin, Texas
| | - Dongwoo Hahn
- Human Performance Laboratory, Department of Kinesiology and Health Education, University of Texas at Austin , Austin, Texas
| | - Brian K Leary
- Human Performance Laboratory, Department of Kinesiology and Health Education, University of Texas at Austin , Austin, Texas
| | - Edward F Coyle
- Human Performance Laboratory, Department of Kinesiology and Health Education, University of Texas at Austin , Austin, Texas
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Weatherall AD, Bennett TR, Lovell M, Fung W, de Lima J. Staged intraperitoneal brachytherapy and hyperthermic intraperitoneal chemotherapy in an adolescent: novel anesthetic challenges for pediatric anesthetists. Paediatr Anaesth 2017; 27:338-345. [PMID: 28211128 DOI: 10.1111/pan.13094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2016] [Indexed: 12/13/2022]
Abstract
Newer techniques that have found a place in cancer management in adults are offered far less commonly in pediatric patients. We present a case of a patient with recurrent Wilms' tumor managed with a novel combination of cytoreductive surgery, intraperitoneal brachytherapy, and subsequent hyperthermic intraperitoneal chemotherapy. Each stage presents challenges that the pediatric anesthetist is unlikely to have faced before. Such cases require flexibility and thorough planning to manage the combination of major surgery, remote anesthesia with brachytherapy and hyperthermic chemotherapy with its potential for metabolic derangement, significant fluid shifts, analgesic care, and potential exposure of staff to cytotoxic agents. Comprehensive care can be offered in pediatric centers.
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Affiliation(s)
- Andrew D Weatherall
- Department of Anaesthesia, The Children's Hospital at Westmead, Sydney, Australia
| | - Tristan R Bennett
- Department of Anaesthesia, Middlemore Hospital, Auckland, New Zealand
| | - Mark Lovell
- Department of Anaesthesia, The Children's Hospital at Westmead, Sydney, Australia
| | - Winnie Fung
- Department of Anaesthesia, The Children's Hospital at Westmead, Sydney, Australia
| | - Jonathan de Lima
- Department of Anaesthesia, The Children's Hospital at Westmead, Sydney, Australia
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Bain AR, Nybo L, Ainslie PN. Cerebral Vascular Control and Metabolism in Heat Stress. Compr Physiol 2016; 5:1345-80. [PMID: 26140721 DOI: 10.1002/cphy.c140066] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This review provides an in-depth update on the impact of heat stress on cerebrovascular functioning. The regulation of cerebral temperature, blood flow, and metabolism are discussed. We further provide an overview of vascular permeability, the neurocognitive changes, and the key clinical implications and pathologies known to confound cerebral functioning during hyperthermia. A reduction in cerebral blood flow (CBF), derived primarily from a respiratory-induced alkalosis, underscores the cerebrovascular changes to hyperthermia. Arterial pressures may also become compromised because of reduced peripheral resistance secondary to skin vasodilatation. Therefore, when hyperthermia is combined with conditions that increase cardiovascular strain, for example, orthostasis or dehydration, the inability to preserve cerebral perfusion pressure further reduces CBF. A reduced cerebral perfusion pressure is in turn the primary mechanism for impaired tolerance to orthostatic challenges. Any reduction in CBF attenuates the brain's convective heat loss, while the hyperthermic-induced increase in metabolic rate increases the cerebral heat gain. This paradoxical uncoupling of CBF to metabolism increases brain temperature, and potentiates a condition whereby cerebral oxygenation may be compromised. With levels of experimentally viable passive hyperthermia (up to 39.5-40.0 °C core temperature), the associated reduction in CBF (∼ 30%) and increase in cerebral metabolic demand (∼ 10%) is likely compensated by increases in cerebral oxygen extraction. However, severe increases in whole-body and brain temperature may increase blood-brain barrier permeability, potentially leading to cerebral vasogenic edema. The cerebrovascular challenges associated with hyperthermia are of paramount importance for populations with compromised thermoregulatory control--for example, spinal cord injury, elderly, and those with preexisting cardiovascular diseases.
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Affiliation(s)
- Anthony R Bain
- Centre for Heart Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan Campus, Kelowna, Canada
| | - Lars Nybo
- Department of Nutrition, Exercise and Sport Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Philip N Ainslie
- Centre for Heart Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan Campus, Kelowna, Canada
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Chiesa ST, Trangmar SJ, Kalsi KK, Rakobowchuk M, Banker DS, Lotlikar MD, Ali L, González-Alonso J. Local temperature-sensitive mechanisms are important mediators of limb tissue hyperemia in the heat-stressed human at rest and during small muscle mass exercise. Am J Physiol Heart Circ Physiol 2015; 309:H369-80. [PMID: 25934093 PMCID: PMC4504966 DOI: 10.1152/ajpheart.00078.2015] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/27/2015] [Indexed: 11/30/2022]
Abstract
Limb tissue and systemic blood flow increases with heat stress, but the underlying mechanisms remain poorly understood. Here, we tested the hypothesis that heat stress-induced increases in limb tissue perfusion are primarily mediated by local temperature-sensitive mechanisms. Leg and systemic temperatures and hemodynamics were measured at rest and during incremental single-legged knee extensor exercise in 15 males exposed to 1 h of either systemic passive heat-stress with simultaneous cooling of a single leg (n = 8) or isolated leg heating or cooling (n = 7). Systemic heat stress increased core, skin and heated leg blood temperatures (Tb), cardiac output, and heated leg blood flow (LBF; 0.6 ± 0.1 l/min; P < 0.05). In the cooled leg, however, LBF remained unchanged throughout (P > 0.05). Increased heated leg deep tissue blood flow was closely related to Tb (R2 = 0.50; P < 0.01), which is partly attributed to increases in tissue V̇O2 (R2 = 0.55; P < 0.01) accompanying elevations in total leg glucose uptake (P < 0.05). During isolated limb heating and cooling, LBFs were equivalent to those found during systemic heat stress (P > 0.05), despite unchanged systemic temperatures and hemodynamics. During incremental exercise, heated LBF was consistently maintained ∼0.6 l/min higher than that in the cooled leg (P < 0.01), with LBF and vascular conductance in both legs showing a strong correlation with their respective local Tb (R2 = 0.85 and 0.95, P < 0.05). We conclude that local temperature-sensitive mechanisms are important mediators in limb tissue perfusion regulation both at rest and during small-muscle mass exercise in hyperthermic humans.
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Affiliation(s)
- Scott T Chiesa
- Centre for Sports Medicine and Human Performance, Brunel University London, Uxbridge, UK; and
| | - Steven J Trangmar
- Centre for Sports Medicine and Human Performance, Brunel University London, Uxbridge, UK; and
| | - Kameljit K Kalsi
- Centre for Sports Medicine and Human Performance, Brunel University London, Uxbridge, UK; and
| | - Mark Rakobowchuk
- Centre for Sports Medicine and Human Performance, Brunel University London, Uxbridge, UK; and
| | - Devendar S Banker
- Centre for Sports Medicine and Human Performance, Brunel University London, Uxbridge, UK; and Department of Anaesthetics, Ealing Hospital NHS Trust, Southall, UK
| | - Makrand D Lotlikar
- Centre for Sports Medicine and Human Performance, Brunel University London, Uxbridge, UK; and Department of Anaesthetics, Ealing Hospital NHS Trust, Southall, UK
| | - Leena Ali
- Centre for Sports Medicine and Human Performance, Brunel University London, Uxbridge, UK; and Department of Anaesthetics, Ealing Hospital NHS Trust, Southall, UK
| | - José González-Alonso
- Centre for Sports Medicine and Human Performance, Brunel University London, Uxbridge, UK; and
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Keller DM, Sander M, Stallknecht B, Crandall CG. α-Adrenergic vasoconstrictor responsiveness is preserved in the heated human leg. J Physiol 2011; 588:3799-808. [PMID: 20693291 DOI: 10.1113/jphysiol.2010.194506] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This study tested the hypothesis that passive leg heating attenuates α-adrenergic vasoconstriction within that limb. Femoral blood flow (FBF, femoral artery ultrasound Doppler) and femoral vascular conductance (FVC, FBF/mean arterial blood pressure), as well as calf muscle blood flow (CalfBF, ¹³³xenon) and calf vascular conductance (CalfVC) were measured during intra-arterial infusion of an α₁-adrenoreceptor agonist, phenylephrine (PE, 0.025 to 0.8 μg kg₋₁ min₋₁) and an α₂-adrenoreceptor agonist, BHT-933 (1.0 to 10 μg kg₋₁ min₋₁) during normothermia and passive leg heating (water-perfused pant leg). Passive leg heating (∼46◦C water temperature) increased FVC from 4.5 ± 0.5 to 11.9 ± 1.3 ml min₋₁ mmHg₋₁ (P < 0.001). Interestingly, CalfBF (1.8±0.2 vs. 2.8±0.3mlmin₋₁ (100 g)₋₁) and CalfVC (2.0±0.3 vs. 3.9±0.5mlmin₋₁ (100 g)₋₁ mmHg₋₁ ×100) were also increased by this perturbation (P <0.05 for both). Infusion of PE and BHT-933 resulted in greater absolute decreases in FVC during leg heating compared to normothermic conditions (maximal decreases in FVC during heating vs. normothermia: PE: 7.8 ± 1.1 vs. 2.8 ± 0.5 ml min₋₁ mmHg₋₁; BHT-933: 8.6 ± 1.7 vs. 2.1 ± 0.4 ml min₋₁ mmHg₋₁; P < 0.01 for both). However, the nadir FVC during drug infusion was higher during passive leg heating compared to normothermic conditions (FVC at highest dose of respective drugs during heating vs. normothermic conditions: PE: 3.7 ± 0.4 vs. 2.0 ± 0.3 ml min₋₁ mmHg₋₁; BHT-933: 3.8 ± 0.2 vs. 2.1 ± 0.3 ml min₋₁ mmHg₋₁; P < 0.001 for both). Leg heating did not alter the responsiveness of CalfBF or CalfVC to either PE or BHT-933. Taken together, these observations suggest that local heating does not decrease α-adrenergic responsiveness.However, heat-induced vasodilatation opposes α-adrenergic vasoconstriction. Furthermore, passive heating of a limb causes not only an increase in skin blood flow but also in muscle blood flow.
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Affiliation(s)
- David M Keller
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, TX 75231, USA
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Arngrímsson SA, Petitt DS, Borrani F, Skinner KA, Cureton KJ. Hyperthermia and maximal oxygen uptake in men and women. Eur J Appl Physiol 2004; 92:524-32. [PMID: 15150660 DOI: 10.1007/s00421-004-1053-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To compare the effect of hyperthermia on maximal oxygen uptake (VO2max) in men and women, VO2max was measured in 11 male and 11 female runners under seven conditions involving various ambient temperatures (Ta at 50% RH) and preheating designed to manipulate the esophageal (Tes) and mean skin (Tsk) temperatures at VO2max. The conditions were: 25 degrees C, no preheating (control); 25, 35, 40, and 45 degrees C, with exercise-induced preheating by a 20-min walk at approximately 33% of control VO2max; 45 degrees C, no preheating; and 45 degrees C, with passive preheating during which Tes and Tsk were increased to the same degree as at the end of the 20-min walk at 45 degrees C. Compared to VO2max (l x min(-1)) in the control condition (4.52+/-0.46 in men, 3.01+/-0.45 in women), VO2max in men and women was reduced with exercise-induced or passive preheating and increased Ta, approximately 4% at 35 degrees C, approximately 9% at 40 degrees C and approximately 18% at 45 degrees C. Percentage reductions (7-36%) in physical performance (treadmill test time to exhaustion) were strongly related to reductions in VO2max (r=0.82-0.84). The effects of hyperthermia on VO2max and physical performance in men and women were almost identical. We conclude that men and women do not differ in their thermal responses to maximal exercise, or in the relationship of hyperthermia to reductions in VO2max and physical performance at high temperature. Data are reported as mean (SD) unless otherwise stated.
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Goldstein DS, Eisenhofer G. Sympathetic Nervous System Physiology and Pathophysiology in Coping with the Environment. Compr Physiol 2001. [DOI: 10.1002/cphy.cp070402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Smolander J, Louhevaara V. Effect of heat stress on muscle blood flow during dynamic handgrip exercise. EUROPEAN JOURNAL OF APPLIED PHYSIOLOGY AND OCCUPATIONAL PHYSIOLOGY 1992; 65:215-20. [PMID: 1396649 DOI: 10.1007/bf00705084] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
During exercise in a hot environment, blood flow in the exercising muscles may be reduced in favour of the cutaneous circulation. The aim of our study was to examine whether an acute heat exposure (65-70 degrees C) in sauna conditions reduces the blood flow in forearm muscles during handgrip exercise in comparison to tests at thermoneutrality (25 degrees C). Nine healthy men performed dynamic handgrip exercise of the right hand by rhythmically squeezing a water-filled rubber tube at 13% (light), and at 34% (moderate) of maximal voluntary contraction. The left arm served as a control. The muscle blood flow was estimated as the difference in plethysmographic blood flow between the exercising and the control forearm. Skin blood flow was estimated by laser Doppler flowmetry in both forearms. Oesophageal temperature averaged 36.92 (SEM 0.08) degrees C at thermoneutrality, and 37.74 (SEM 0.07) degrees C (P less than 0.01) at the end of the heat stress. The corresponding values for heart rate were 58 (SEM 2) and 99 (SEM 5) beats.min-1 (P less than 0.01), respectively. At 25 degrees C, handgrip exercise increased blood flow in the exercising forearm above the control forearm by 6.0 (SEM 0.8) ml.100 ml-1.min-1 during light exercise, and by 17.9 (SEM 2.5) ml.100 ml-1.min-1 during moderate exercise. In the heat, the increases were significantly higher: 12.5 (SEM 2.2) ml.100 ml-1.min-1 at the light exercise level (P less than 0.01), and 32.2 (SEM 5.9) ml.100 ml-1.min-1 (P less than 0.05) at the moderate exercise level.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J Smolander
- Department of Physiology, Institute of Occupational Health, Vantaa, Finland
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Asoh T, Shirasaka C, Uchida I, Tsuji H. Effects of indomethacin on endocrine responses and nitrogen loss after surgery. Ann Surg 1987; 206:770-6. [PMID: 3689013 PMCID: PMC1493328 DOI: 10.1097/00000658-198712000-00014] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
In 14 patients who had elective gastrectomy, 50 mg of indomethacin was administered intrarectally every 6-8 hours after operation until postoperative day 3. Body temperature, plasma cortisol and glucagon concentrations, blood glucose level, urinary catecholamine level, and urinary nitrogen excretion level were compared with those of 16 patients who did not receive indomethacin. Postoperative fever was significantly reduced by indomethacin. Plasma cortisol levels in the indomethacin-treated group were significantly lower on postoperative days 2 and 3. Postoperative increases in plasma glucagon and blood glucose levels were not influenced by indomethacin administration. Urinary epinephrine excretion tended to be inhibited, and urinary norepinephrine excretion was significantly inhibited in the indomethacin-treated group after operation. Urinary nitrogen excretion levels during the observation period were significantly less in the indomethacin-treated group. The cumulative urinary nitrogen level from postoperative days 1-3 in the indomethacin-treated group was 82% of that in the control group. These results indicated that fever reduction by indomethacin after surgery resulted in reduced protein loss, associated with attenuated cortisol and catecholamine responses.
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Affiliation(s)
- T Asoh
- Department of Surgery, Kyushu University, Beppu, Japan
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Faithfull NS, Van Den Berg AP, Van Rhoon GC. Cardiovascular and oxygenation changes during whole body hyperthermia. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1982; 157:57-70. [PMID: 7158525 DOI: 10.1007/978-1-4684-4388-2_7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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