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Microtubule reassembly in surface-activated platelets.

It is generally accepted that a circumferential microtubule supports the discoid shape of resting platelets. The fate of the many-coiled polymer following platelet activation, however, has been a subject of considerable debate. Morphological investigations have suggested that the circumferential coils are constricted into tight rings around centrally concentrated organelles during platelet shape change. Biochemical studies employing colchicine-binding assays, on the other hand, have indicated that the bundle of microtubules dissolves almost completely within seconds after activation and reassembles in a new location one to four minutes later. The present study has accepted the latter hypothesis in order to examine the second part of the disassembly-reassembly theory proposed in biochemical studies. Platelets exposed to low temperatures sufficient to remove all microtubules were placed on glass slides and microscope grids to cause surface activation during rewarming. The combined stimuli of rewarming and surface activation might have been expected to cause more rapid assembly than warming alone or activation alone. This was not the case. Reassembly of microtubules during rewarming and simultaneous surface activation was not accelerated. In contrast to the constriction of microtubule rings observed during activation in control platelets, the diameters of coils that developed in chilled platelets one to two hours after rewarming and surface activation were twice those of control cells.

Blood Platelets↗

[Treatment of severe accidental hypothermia with a simple extracorporeal circuit].

A simple method allows rewarming severe accidental hypothermia patients by an extra-corporal veno-venous circuit. Blood is removed from the femoral vein and brought to infusion pump accelerator which sends it through a blood-rewarmer before reinjecting it into the terminal jugular or sub-clavian vein. This allows the heart to be rewarmed preferentially. The blood is heparinized upon entering the circuit and later neutralized with protamine sulfate upon leaving it. Five severely hypothermic patients (average temperature: 26.5 degrees C) were treated using this technique. Rapid improvement was obtained with disappearance of cardiovascular shock within one hour. Rectal temperature increased by 1.84 degrees C.h-1 and became normal in 6 hours. No complications were encountered. Particularly, there were no incidents of shock due to rapid rewarming and no secondary biological disturbances observed imputable to the extra-corporal circuit. It should be emphasized that the equipment used is readily available in most Emergency and Intensive Care Units.

Accidents↗

[Accidental hypothermia. Physiopathology, clinical manifestations and treatment].

The article reviews pathophysiology and clinical problems. During deep hypothermia, criteria for death are obscured. Prehospital treatment should be vigorous resuscitation on broad indications. Asystole or ventricular fibrillation is common. Drugs are contraindicated, with the possible exception of bretyllium. Electro-conversion of the heart is usually impossible below 28-30 degrees Centigrade. Hypothermic victims must be handled with the utmost care. Rewarming may cause life-threatening arrythmias, afterdrop and "rewarming collapse". Rewarming should take place in hospital only. Different methods of rewarming are discussed. Probably the best way to treat deeply hypothermic victims is by cardiopulmonary bypass.

Accidents↗

Effect of hypothermic hemodilutional cardiopulmonary bypass on plasma sufentanil and catecholamine concentrations in humans.

The effect of hypothermic hemodilutional cardiopulmonary bypass (CPB) on plasma sufentanil and catecholamine concentrations was studied in four groups of ten patients each, receiving four different doses of sufentanil. Samples for measurement of sufentanil were obtained before CPB, at 15, 30, and 45 minutes of CPB, during rewarming, immediately after and 15, 60, and 240 minutes after CPB. In addition, in groups III and IV, which received the highest dose of sufentanil, blood samples were also obtained for measurement of plasma levels of epinephrine and norepinephrine. Sufentanil concentration decreased in all groups with the start of CPB (group I, 2.92 +/- 0.2 to 2.04 +/- 0.2; group II, 3.30 +/- 0.3 to 1.51 +/- 0.2; group III, 7.08 +/- 0.7 to 3.45 +/- 0.3; group IV, 10.33 +/- 0.5 to 4.59 +/- 0.5 ng/ml). No further decreases occurred during CPB but increases occurred with rewarming. The first measurement after CPB approached the concentration before CPB (group I, 2.82 +/- 0.3; group II, 2.56 +/- 0.5; group III, 4.42 +/- 0.4; group IV, 6.10 +/- 0.4 ng/ml). Norepinephrine concentrations demonstrated a wide variability with no significant changes. Epinephrine levels increased significantly during rewarming in both groups (group III, 141 +/- 23 to 279 +/- 79 pg/ml; P less than 0.05; group IV, 105 +/- 24 to 267 +/- 68 pg/ml, P less than 0.05). The stability of plasma sufentanil concentrations during CPB suggest that no measurable metabolism or excretion occurred. The increase with rewarming and after CPB suggest significant sequestration.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthetics↗

Accidental hypothermia.

Accidental hypothermia is an acute medical emergency with a high mortality rate. Physiologic derangements include hypoxemia, hypotension, acidosis, and arrhythmias. Management consists of careful monitoring rewarming, vigorous supportive care, and treatment of underlying and complicating disorders. Active core rewarming is recommended for hypothermia with associated cardiovascular insufficiency or instability and rapid core rewarming for hypothermia with cardiovascular collapse. Otherwise, passive or active external rewarming may be used. Good supportive care with correction of physiologic disturbances and vigorous treatment of underlying and complicating disorders are important in improving the survival rate.

Acidosis↗

[Energy metabolism of the isolated liver at subzero temperatures under the control of a newly developed system].

If the isolated liver could be preserved at subzero temperatures, it would keep viability for a longer time. But the liver is so large that it is difficult to cool and rewarm with an uniform heat distribution for minimizing differential effects of biochemical reactions. A new system was developed in order to cool and rewarm the liver uniformly. The apparatus consists of two heat exchangers, one temperature controller using a computer system and one hypothermic bath. The temperature of a perfusate and an immersing solution was controlled at the same time. Wistar rat livers were cooled to -4 degrees C and rewarmed to +4 degrees C by this system using 10% DMSO (Me2SO) solution. The perfusion pressure was 8-10 cmH2O and the liver temperature was uniformly controlled when the perfusion flow rate was 0.1 ml/g X liver/min and the temperature gradient was programmed at 2 degrees C/min. Levels of adenine nucleotides and histologic findings were evaluated in the livers which were cooled to -4 degrees C by this system and preserved for 24 hours. Levels of adenine nucleotides were higher in the liver preserved with -4 degrees C 10% DMSO Collins' M solution for 24 hours compared with those of +4 degrees C Collins' M for 24 hours and +4 degrees C lactated Ringer solution for 1 or 2 hours. Light microscopic findings of the liver preserved at -4 degrees C for 24 hours showed slight cellular atrophy and sinusoidal dilatation. But cellular and vascular structures appeared to be almost normally maintained. The liver preserved at +4 degrees C for 24 hours showed diffuse necrosis of liver cells and architectural destruction of the lobules. This system was useful for controlling the liver temperature in cooling and rewarming. The viability of livers at subzero temperatures controlled with this system was better than those above 0 degree C. This method may prolong the preservation period of the liver with a good viability.

Animals↗

[Deep accidental hypothermia without cardiorespiratory arrest].

A case is reported of profound accidental hypothermia with spontaneous cardiac activity in a patient presenting several risk factors. The rewarming from 23.5 degrees C to 36.5 degrees C by partial cardio-pulmonary bypass was carried out without complications and in particular without cardiac arrythmia. As far as we are aware this is the twelfth case of profound accidental hypothermia reported in the literature in which rewarming was carried out by this method and the fourth case not involving cardiac arrest. Rapid rewarming by partial cardio-pulmonary bypass could be useful in patients with profound accidental hypothermia without cardiac arrest, the most serious complication being, precisely, cardiac arrest during rewarming.

Adult↗

Effect of hypothermia on survival time and ECG in rats with acute blood loss.

The effects of hypothermia on survival time and ECGs were investigated in hemorrhagic-shocked rats. Acute blood loss corresponding to LD84 was achieved within 1 min through cannulation of the carotid artery. Immediately following the hemorrhagic episode, extracorporeal cooling was performed by placing the animals, with ice packs attached to their lateral sides, in a cold water bath. Rewarming was achieved by removing the ice packs and resetting the temperature of the water bath to 37 degrees C. With this system, the survival time of the hemorrhagic rats was lengthened from 40 to 60 min without rewarming and to 123 min with rewarming. ECGs showed sinus bradycardia, prolonged PR and QRS intervals, AV block, and finally ventricular fibrillation in both the control and hemorrhagic groups during extracorporeal cooling. During rewarming, the above ECG changes returned to normal in the control group as did body temperature. In contrast, animals in the hemorrhagic group did not survive. Body temperature in this group began to rise toward normal, and above ECG changes showed slight but not complete improvement. It is concluded that extracorporeal cooling can lengthen the survival time of hemorrhagic-shocked rats and that recovery of the disturbed conduction system is a prerequisite for survival from severe hypothermia.

Acute Disease↗

Mechanism of shape change in chilled human platelets.

The so-called cold activation of platelets that precludes refrigeration of platelets for storage has long been recognized, but its mechanism has remained a mystery. Cooling of discoid resting platelets to temperatures below 15 degrees C causes shape distortions, and the chilled cells rewarmed to above 25 degrees C are spheres rather than discs. As platelet shape change responsive to receptor activation at normal temperatures requires the remodeling of an actin scaffolding (Hartwig JH, 1992, J Cell Biol 118:1421-1442), we examined the role of actin in the morphologic changes induced by cooling. The addition of actin monomers onto the fast-exchanging (barbed) ends of actin filaments accompanies the initial physiologic platelet shape changes, and a key control point in this growth is the removal of proteins (caps) from the filament ends. This uncapping of actin filament ends is mediated by polyphosphoinositide aggregates in vitro, suggesting that cold-induced phase changes in membrane lipids might uncap actin filaments and thereby account for actin assembly-mediated shape alterations during cooling. Consistent with this hypothesis, reversible inhibition of actin assembly with cytochalasin B prevented the distortions in shape, although cooled platelets had increased actin nucleation sites and became spherical. Another step in normal platelet shape changes requires the severing of actin filaments that maintain the resting platelet. The proteins that sever initially bind to the broken filament ends, and uncapping of these fragmented filaments provides numerous nucleation sites for growth of actin filaments to fill in spreading filopodia and lamellae. Actin filament fragmentation requires a rise in intracellular calcium, and we showed that chilling platelets from 37 degrees C to 4 degrees C increases free cytosolic calcium levels from 80 nmol/L to approximately 200 nmol/L in minutes, thus providing an explanation for the spherical shape of cooled, rewarmed platelets. Blocking the calcium transient with nanomolar concentrations of the permeant calcium chelators Quin-2 and Fura-2 prevented the increase in nucleation sites and the sphering, but not the other shape changes of chilled and rewarmed platelets. However, a combination of micromolar cytochalasin B and millimolar intracellular calcium chelators preserved the discoid shapes of chilled and rewarmed platelets. After removal of cytochalasin B and addition of sufficient extracellular calcium, these platelets responded with normal morphologic alterations to glass and thrombin activation.

Actin Cytoskeleton↗

UW-preservation of cultured human gallbladder epithelial cells: phenotypic alterations and differential mucin gene expression in the presence of bile.

In orthotopic liver transplantation, extended cold ischemia of the graft may induce cell damage, particularly in biliary epithelium. We have investigated the effects of a cold University of Wisconsin (UW) solution on cultured human gallbladder biliary epithelial cells (GBEC) exposed or not exposed to stagnant bile. In UW solution, morphological alterations of cultured GBEC were not prominent under light microscopy after 16 hours at 4 degrees C, being more striking after 24 to 48 hours. Ultrastructural examination of GBEC showed a condensation of chromatin at the periphery of the nuclei after 16 hours in cold UW solution. Both protein and DNA syntheses were strikingly reduced in these cells. After rewarming in standard Williams' medium at 37 degrees C for 24 hours, cultured GBEC exhibited both normal morphology and function. As in both freshly isolated and routinely cultured GBEC, rewarmed cells expressed various mucin genes, namely MUC1, MUC3, MUC4, MUC5AC, and MUC5B genes, whereas MUC2 mRNAs were barely detectable. A dramatic decline in the steady-state mRNA levels of both MUC3 and MUC5B was found in cultured GBEC versus freshly isolated cells. Addition of bile into UW solution at 4 degrees C had no significant effect on GBEC morphology and DNA and protein syntheses. When bile was added during the rewarming period, both protein and DNA syntheses were strongly reduced. Addition of bile during either storage in UW solution or rewarming period induced increased steady-state MUC2, MUC3 and MUC5AC mRNA levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenosine↗

Treatment of mild immersion hypothermia by forced-air warming.

Forced-air warming is used for prevention or reversal of hypothermia in surgical patients. In the present study, the efficacy of this system for treatment of immersion hypothermia was evaluated. Six men and two women were twice immersed in 8 degrees C water until hypothermic. They were then rewarmed by either: 1) shivering-only inside a sleeping bag; or 2) forced-air warming. Esophageal and skin temperature, cutaneous heat flux and metabolism were measured. Afterdrop (+/- SD) during forced-air warming (0.43 +/- 0.26 degrees C) was approximately 30% less than during shivering (0.61 +/- 0.26 degrees C) (p < 0.001). Rewarming rate during forced-air warming (3.26 +/- 1.8 degrees C.h-1) was not significantly different from shivering (3.02 +/- 1.2 degrees C.h-1). Skin temperature was higher during forced-air warming by 3.7 degrees C early and 4.5 degrees C after 35 min of warming. Heat production increased by 77 W over the initial 20 min of shivering, and subsequently declined, compared to an immediate decrease with forced-air warming. During shivering heat flux ranged from 30 W early in rewarming, to 50 W after 35 min, compared to -237 W and -163 W respectively, for forced-air warming. Forced-air warming attenuated afterdrop and the metabolic stress of shivering while maintaining an average rate of rewarming comparable to shivering. Forced-air warming is a safe, simple, noninvasive treatment and could be used effectively in an emergency medical facility, and possibly in some rescue/emergency vehicles or marine vessels.

Adult↗

Thermography and nailfold capillaroscopy as noninvasive measures of circulation in children with Raynaud's phenomenon.

OBJECTIVE: To determine in a pilot study the feasibility of noninvasive techniques of (a) measurement of rewarming response after a standard cold challenge test (using thermographic imaging) and (b) measurement of nailfold capillary dimensions using video capillaroscopy, in the assessment of children presenting with Raynaud's phenomenon (RP). METHODS: Ten children with RP and 10 age matched healthy controls were studied. No child had definite evidence of underlying connective tissue disease. RESULTS: Children with RP had abnormal rewarming curves. The gradient of the rewarming curve was significantly lower in children with RP (median 1.5 vs 5.0 degrees C/min in controls; p = 0.015), and there was a trend for the lag time (the interval between the end of the cold challenge and the onset of rewarming) to be increased in children with RP (median 4.7 vs 0.5 min in controls; p = 0.08). Capillary dimensions were measured in 7 of the children with RP, and were similar to those of healthy controls. CONCLUSION: Thermography and nailfold capillaroscopy are feasible in children and should be further evaluated.

Adolescent↗

Infrared thermography in the diagnosis of Raynaud's phenomenon in vibration-induced white finger.

BACKGROUND: Frequent use of vibrating tools over several years may lead to a neurovascular disturbance of finger circulation with the development of typical Raynaud's phenomenon, attacks being triggered by vibration and/or cold exposure. The condition is recognized as an occupational disease and known as vibration-induced white finger (VWF). Aim of the present study was to evaluate the usefulness of infrared thermography (IRT) with a cold provocation test in the diagnosis of Raynaud's phenomenon in VWF. PATIENTS AND METHODS: 24 patients with the diagnosis of VWF, previously established by other methods, were compared with 12 matched control subjects. We carried out IRT-measurements simultaneously on both hands before, directly after and 5, 10, 15, 20, and 30 mins following a 3 min exposure of both hands to a waterbath of 12 degrees C. The results of temperature measurements of all fingers were analyzed and the time to complete rewarming of all fingers was recorded. RESULTS: The basal thermograms did not differ between both groups, whereas the mean finger temperatures after cold exposure were significantly lower in VWF-patients compared to controls, with a considerable individual overlap between both groups. Therefore, determination of absolute finger temperature reveals not to be a useful diagnostic tool in individual cases, but might be helpful for pharmacological studies (group-analysis). In contrast to absolute finger temperatures, the parameter of rewarming time after cold exposure revealed to be diagnostic on an individual basis: a complete rewarming after 15 min indicates a normal vascular reactivity and an incomplete rewarming 30 min following the cold provocation points to an impaired vascular reactivity due to VWF. CONCLUSIONS: IRT revealed to be a useful tool in the diagnosis of Raynaud's phenomenon in VWF, and provides a sufficient documentation suitable for further follow-up examination.

Adult↗

[Accidental urban hypothermia. Severe hypothermia of 20.7 degrees C].

In emergency medicine accidental hypothermia (<35 degrees C) is a common epiphenomenon of many medical conditions. In contrast, severe hypothermia (<28 degrees C) occurs very seldom and presents a difficult medical situation. Here we present a female patient with severe urban hypothermia (core temperature of 20.7 degrees C) and circulatory arrest. An overview of the emergency treatment, rewarming strategy with extracorporeal circulation and the clinical course will be given. The survival of the patient and the favorable neurological outcome will be discussed considering the current literature. Due to the paucity of treatment guidelines or clear prognostic criteria of withholding or withdrawing treatment in severe hypothermia, the decision of prolonged resuscitation and rewarming strategy is solely dependent on the individual judgement and medical experience of the physician. The positive clinical outcome which can be gleaned from case reports or single retrospective studies should encourage the emergency physician to selectively rewarm a severe hypothermic patient with extracorporeal circulation under prolonged CPR.

Adult↗

Temperature monitoring during cardiopulmonary bypass--do we undercool or overheat the brain?

OBJECTIVE: Brain cooling is an essential component of aortic surgery requiring circulatory arrest and inadequate cooling may lead to brain injury. Similarly, brain hyperthermia during the rewarming phase of cardiopulmonary bypass may also lead to neurological injury. Conventional temperature monitoring sites may not reflect the core brain temperature (Tdegrees). We compared jugular bulb venous temperatures (JB) during deep hypothermic circulatory arrest and normothermic bypass with Nasopharyngeal (NP), Arterial inflow (AI), Oesophageal (O), Venous return (VR), Bladder (B) and Orbital skin (OS) temperatures. METHODS: 18 patients undergoing deep hypothermia (DH) and 8 patients undergoing normothermic bypass (mean bladder Tdegrees-36.29 degreesC) were studied. For DH, cooling was continued to 15 degreesC NP (mean cooling time-66 min). At pre-determined arterial inflow Tdegrees, NP, JB and O Tdegree's were measured. A 6-channel recorder continuously recorded all Tdegree's using calibrated thermocouples. RESULTS: During the cooling phase of DH, NP lagged behind AI and JB Tdegree's. All these equilibrated at 15 degreesC. During rewarming, JB and NP lagged behind AI and JB was higher than NP at any time point. During normothermic bypass, although NP was reflective of the AI and JB Tdegrees trends, it underestimated peak JB Tdegrees (P=0.001). Towards the end of bypass, peak JB was greater than the arterial inflow Tdegrees (P=0.023). CONCLUSIONS: If brain venous outflow Tdegrees (JB) accurately reflects brain Tdegrees, NP Tdegrees is a safe surrogate indicator of cooling. During rewarming, all peripheral sites underestimate brain temperature and caution is required to avoid hyperthermic arterial inflow, which may inadvertently, result in brain hyperthermia.

Adult↗

Safety of deliberate intraoperative and postoperative hypothermia for patients undergoing coronary artery surgery: a randomized trial.

BACKGROUND: Hypothermia in the perioperative period is associated with adverse effects, particularly bleeding. Before termination of cardiopulmonary bypass, rewarming times and perfusion temperatures are often increased to avoid post-cardiopulmonary bypass hypothermia and the presumed complications. This practice may, however, also have adverse effects, particularly cerebral hyperthermia. We present safety outcomes from a trial in which patients undergoing coronary artery surgery were randomly assigned to normothermia or hypothermia for the entire surgical procedure. METHODS: Consenting patients over the age of 60 years presenting for a first, elective coronary artery surgery with cardiopulmonary bypass were randomly assigned to having their nasopharyngeal temperature maintained at either 37 degrees C (group N; 73 patients) or 34 degrees C (group H; 71 patients) throughout the intraoperative period, with no rewarming before arrival in the intensive care unit. All received tranexamic acid. RESULTS: There was no clinically important difference in intraoperative blood product or inotrope use. Temperatures on arrival in the intensive care unit were 36.7 degrees C +/- 0.38 degrees C and 34.3 degrees C +/- 0.38 degrees C in groups N and H, respectively. Blood loss during the first 12 postoperative hours was 596 +/- 356 mL in group N and 666 +/- 405 mL in group H (mean difference +/- 95% confidence interval, 70 +/- 126 mL; P =.28). There was no significant difference in blood product utilization, intubation time, time in the hospital, myocardial infarction, or mortality. The mean time in the intensive care unit was 8.4 hours less in the hypothermic group (P =.02). CONCLUSIONS: Our data support the safety of perioperative mild hypothermia in patients undergoing elective nonreoperative coronary artery surgery with cardiopulmonary bypass. These findings suggest that complete rewarming after hypothermic cardiopulmonary bypass is not necessary in all cases.

Aged↗

Safety of 65 degrees C intravenous fluid for the treatment of hypothermia.

BACKGROUND: To demonstrate the safety and efficacy of 65 degrees C (149 degrees F) centrally administered intravenous fluid (CIVF) compared to conventional 40 degrees C (104 degrees F) CIVF in the treatment of hypothermia. METHOD: Ten beagles (9-13 kg) were prospectively randomized to receive 65 degrees C or 40 degrees C CIVF. They were anesthetized and data were collected at baseline, during hypothermia, and after 1 and 2 hours of rewarming. The plasma free/total hemoglobin (PFHb/THb) was measured to detect hemolysis. Each subject was cooled to 30 degrees C (86 degrees F) and then received either 65 degrees C or 40 degrees C CIVF through a specialized catheter in the superior vena cava for 2 hours in addition to conventional rewarming techniques. All subjects survived 7 days, after which they were sacrificed and a complete autopsy was performed. RESULTS: The rewarming rate was 3.7 degrees C/hr in the 65 degrees C CIVF group and 1.75 degrees C/hr in the 40 degrees C CIVF group. Core temperatures were significantly different after 1 hour (33.4 degrees +/- 0.77 degrees versus 31.7 degrees +/- 0.57 degrees, P < 0.01) and 2 hours (37 degrees +/- 1.03 degrees versus 33.4 degrees +/- 0.89 degrees, P < 0.001). PFHb/THb was not different. Two intimal injuries occurred in each group but these were remote from the infusion site. Blinded examination by two pathologists could not differentiate the etiology of these injuries from mechanical trauma. CONCLUSION: CIVF at 65 degrees C is a safe and effective means of treating hypothermia.

Animals↗

Cold tolerance: behavioral differences following single or multiple cold exposures.

Previous research has demonstrated that repeated exposure to cold water results in cold tolerance. The present set of experiments examined whether spontaneous behavioral activity and the rate of rewarming differed between cold tolerant and nontolerant rats. Animals receiving six cold exposures (one per day) were compared to subjects receiving a single cold exposure but cooled to match the final day temperature of the six-exposure group. Immediately following the final or only cold exposure, activity was measured by an activity monitor (Exp. 1) or was videotaped and scored by an independent observer (Exp. 2). Furthermore, rats' temperatures were monitored for 90 min (Exp. 2) and 60 min (Exp. 3) following the activity measurement. The results indicated that cold-tolerant rats exhibited activity similar to normal, noncooled subjects, whereas the activity in the single exposure group was impeded. Moreover, rats in the multiple exposure groups rewarmed more quickly than subjects in the single exposure condition. The third experiment also examined if the procedures of Experiments 1 and 2 resulted in associative cold tolerance. Experiment 3 replicated earlier findings, which have shown that exposure to the same cold stimulus in an altered context resulted in a loss of tolerance. These findings suggest that the processing of contextual stimuli is necessary for the acquisition of cold tolerance and that behavioral activity and rewarming rates can be used as alternative measures of cold tolerance.

Animals↗