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A new method to assess gastric mucosa rewarming time in patients with portal hypertension.

It is possible that the mucosal damage in congestive gastropathy of portal hypertensive patients may have an ischemic basis, since rewarming time in other sites correlates with local blood flow, a method was designed to assess the capacity of the gastric mucosa to rewarm the stomach after a cold challenge, as an index of ischemia. Eleven control subjects and 15 patients with portal hypertension (10 treated with sclerotherapy) were studied with an integrated circuit temperature transducer connected to a digital display. A balloon containing the temperature transducer inside was reversibly fixed 10 cm. proximally to the distal end of a panendoscope. Once upper endoscopy was completed, the balloon placed in the antrum was infused with cooled water (2 degrees C) through a polyethylene tube. The time elapsed for the water to be rewarmed from 20 degrees C to 25 degrees C to 30 degrees C and 20 degrees C to 30 degrees C was measured. Reproducibility of repeated measurements, gave a coefficient of variation of 6%. Total rewarming time was (-mean +/- SD) 178 +/- 51.3 seconds, significantly higher in Portal hypertensive patients as compared to 114 +/- 34.7 seconds in Controls (P < 0.001). (95% Confidence Interval: -X = 63.4 seconds Cl 45.02 to 81.78). 60% of Sensitivity and 100% of Specificity The slower rewarming time in patients with portal hypertension may be the result of mucosal ischaemia, but oedema and cellular infiltration could also affect the heat flow.

Adolescent↗

Appropriate cerebral perfusion pressure during rewarming after therapeutic hypothermia.

This study evaluated the cerebral ischemic parameters during the rewarming period after therapeutic hypothermia to determine the critical cerebral perfusion pressure (CPP) threshold to avoid ischemic deterioration. Cat experimental head injury was induced by inflation of an epidural rubber balloon to maintain intracranial pressure at 30 mmHg under hypothermia. During the rewarming period, CPP was maintained at > or = 120 mmHg, 90 mmHg, and 60 mmHg by controlling the blood pressure. CBF, CMRO2, AVDO2, and cerebral venous oxygen saturation (ScvO2) were measured. Brain extracellular glutamate concentrations were also measured by a dialysis electrode. Histological preparations of all brains were examined under an electron microscope. The cerebral metabolic parameters in animals with CPP of more than 90 mmHg returned to the base values after rewarming. However, ScvO2 was significantly lower (27 +/- 6%) and AVDO2 was significantly higher (9.4 +/- 1.8 ml/100 g/min) after rewarming in the animals with CPP = 60 mmHg, which indicated misery perfusion. Animals with CPP = 60 mmHg also showed increased extracellular glutamate concentration and histological ischemic damage (mitochondrial swelling). CPP of 60 mmHg during the rewarming period is associated with irreversible ischemia, which indicates continuation of cerebral vasoconstriction. Therefore, a CPP of greater than 90 mmHg is required to avoid cerebral ischemia.

Animals↗

Effects of hypothermia and rewarming on phospholipase C-evoked glycerol output in rat myocardial cells.

The combined action of phosphatidylcholine preferring phospholipase C (PC-PLC) and intracellular lipases has recently been shown to cause glycerol output in energy deprived rat cardiomyocytes. In the present study we examined the effect of hypothermia and rewarming on PC-PLC evoked glycerol output in freshly isolated, calcium-tolerant myocytes. The cells were preincubated for 60 min at hypothermic (5 degrees C) or normothermic (37 degrees C) conditions in Krebs-Henseleit bicarbonate buffer (pH 7.4) supplemented with 1 mM DL-carnitine, 1% B.S.A. and 5 mM glucose. Addition of PC-PLC resulted in a significantly higher (P less than 0.05) output of glycerol in myocytes undergoing rewarming than in myocytes kept constantly at 5 degrees C or 37 degrees C. The values obtained for PC-PLC induced glycerol output (difference in glycerol output between incubations with and without PC-PLC) were 6.77 +/- 2.6 (37 degrees C), 4.54 +/- 1.7 (5 degrees C) and 22.85 +/- 5.9 (5-37 degrees C) nmol/10(6) cells.h. Rewarming in addition caused a significantly higher (P less than 0.05) leakage of lactate dehydrogenase (LDH) from the rewarmed cells as compared to cells at constant temperatures (5 degrees C or 37 degrees C). However, there was no additional effect of PC-PLC on LDH leakage. The elevated PC-PLC induced glycerol output in rewarmed myocytes was not related to a fall in the percentage of rod-shaped cells or a reduced cellular content of ATP, since no differences could be detected between the various myocyte preparations with respect to these parameters.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenosine Triphosphate↗

Rewarming rates and thermogenesis in hibernating echidnas.

We measured body temperatures (T(b)) in 14 free-ranging echidnas (Tachyglossus aculeatus) using implanted data-loggers. An average of 1020+/-744 days of T(b) data was recorded from each animal. The average maximum T(b) was 35.3+/-0.7 degrees C (n=14), and the lowest T(b) was 4.7 degrees C. Detailed analysis of rewarming events from four echidnas showed rewarming time to be dependent on initial T(b) (rewarming time in hours=15.6-0.41T(initial), n=31) with an average rewarming rate of 1.9+/-0.4 degrees C h(-1). Based on an hourly sampling rate, the peak rewarming rate was found to be 7.2+/-0.8 degrees C h(-1) (n=12), which was measured at a mean T(b) of 26.2+/-2.4 degrees C. This rate of heating was calculated to be equivalent to a peak oxygen consumption rate of 1.4+/-0.2 ml O2 g h(-1), approximately 9 times the basal metabolic rate. We found that a plot of rate of change of T(b) against T(b) for the entire data set from an individual echidna provided a useful summary and analytical tool.

Animals↗

Energy metabolism, thermogenesis and body mass regulation in Brandt's voles (Lasiopodomys brandtii) during cold acclimation and rewarming.

Environmental cues play important roles in the regulation of an animal's physiology and behavior. The purpose of the present study was to test the hypothesis that ambient temperature was a cue to induce adjustments in body mass, energy intake and thermogenic capacity, associated with changes in serum leptin levels in Brandt's voles (Lasiopodomys brandtii). We found that Brandt's voles increased resting metabolic rate (RMR) and energy intake and kept body mass stable when exposed to the cold while showed a significant increase in body mass after rewarming. The increase in body mass after rewarming was associated with the higher energy intake compared with control. Uncoupling protein 1 (UCP1) content in brown adipose tissue (BAT) increased in the cold and reversed after rewarming. Serum leptin levels decreased in the cold while increased after rewarming, associated with the opposite changes in energy intake. Further, serum leptin levels were positively correlated with body mass and body fat mass. Together, these data supported our hypothesis that ambient temperature was a cue to induce changes in body mass and metabolism. Serum leptin, as a starvation signal in the cold and satiety signal in rewarming, was involved in the processes of thermogenesis and body mass regulation in Brandt's voles.

Acclimatization↗

The effects of four different radiant warmer temperature set-points used for rewarming neonates.

Temperatures for rewarming neonates have been established for convection incubators. The purpose of this study was to evaluate the effects on neonates when the skin surface was rewarmed at one of four different levels with an infra-red warmer. A total of 42 normal term neonates were first divided into four groups according to deep rectal temperature on admission; infants in each of the respective groups were then allotted to one of the following skin surface temperature set-point groups: 35, 36, 37 or 38 degrees c for rewarming under a servo-controlled infra-red heat source. Although rewarming at 38 degrees (100.4 degrees F) surfacetemperature bears the theoretic risk of the effects of hyperthermic stress to the neonate, particularly of apnea, the 12 infants rewarmed at this temperature set-point all achieved normal rectal temperatures significantly sooner than the infants in the other three groups without evidence of ill effects. The attainment of a rectal temperature of 37 degrees C within the 4 hr study period and the absence of hypoglycemia in the 38 degrees C skin temperature group was statistically significant when compared to the frequency of occurrence in the other groups.

Body Temperature↗

A comparative study of the effects of carbon dioxide and perfusion rewarming on limited circulatory occlusion during surface hypothermia, under halothane and ether anesthesia.

Effects of the use of 5% CO(2) and surface-rewarming or perfusion- rewarming on safe total circulatory occlusion time, blood gases and carbohydrate metabolism were studied in 25 dogs subjected to surface hypothermia (18 C) and 30 minutes of circulatory occlusion under halothane or ether anesthesia. Under halothane anesthesia, all animals with 100% 0(2) developed motor disorders while one of five surface-rewarmed dogs and none of the perfusion-rewarmed dogs developed motor disorders with 5% CO(2). Under ether anesthesia, all were normal with either 100% 0(2) or when 5% CO(2) was added. Ventricular fibrillation occurred in one dog at 21C under halothane anesthesia with 5% CO(2). Blood lactate levels remained low through hypothermic procedures when 5% CO(2) was used. Perfusion rewarming had little effect on lactate levels. The use of 100% 0(2) resulted in slightly higher lactate levels, especially in the ether anesthetized group, but these levels still remained within the upper limit of the normal range. Significant differences in lactate levels between halothane and ether anesthesia suggest different mechanisms of tissue circulation and metabolism during hypothermia. Halothane anesthesia can be useful with the use of CO(2) for surface hypothermia with 30 minutes circulatory occlusion but is still inferior to ether.

Anesthesia, Inhalation↗

Active core rewarming in neurologic, hypothermic patients: effects on oxygen-related variables.

OBJECTIVES: To determine in hypothermic patients if a) the decrease in oxygen consumption (VO2) is exclusively dependent on the decrease in metabolic rate, or b) as a consequence of the greater hemoglobin affinity for oxygen, hypothermic tissues have impaired oxygen extraction. DESIGN: Clinical, prospective study; sequential measurements of oxygen-related variables during active core rewarming. SETTING: Intensive care unit of a university hospital. PATIENTS: Twelve patients (44 +/- 16 yrs of age) admitted to the intensive care unit with a core temperature of < 34 degrees C due to severe neurologic damage. INTERVENTIONS: Rewarming (with heated enemas, gastric infusions, and heated blankets) to increase body temperature at a rate of approximately 1 degree C/hr. Measurements of oxygen-related variables were performed at a baseline of 31.0 +/- 1.1 degrees C, and repeated at each 1 degree C increase to reach a core temperature of approximately 35 degrees C. MEASUREMENTS AND MAIN RESULTS: Oxygen-related variables of rewarmed patients were allocated into two groups, above or below the observed mean core temperature of 33.1 degrees C recorded for all measurements (n = 45). Comparison of the low core temperature group (31.1 +/- 1.4 degrees C; n = 20) with the high core temperature group (34.7 +/- 0.9 degrees C; n = 25) showed that the group with the lower core temperatures had a significant increase in VO2 index (67 +/- 22 vs. 103 +/- 38 mL/min/m2 [p < .001]), oxygen delivery index (183 +/- 73 vs. 290 +/- 123 mL/min/m2 [p < .001]), and the PO2 value at which hemoglobin was half-saturated with oxygen ([P50] 23 +/- 5.7 vs. 27.7 +/- 5.7 torr [3.0 +/- 0.7 vs. 3.6 +/- 0.7 kPa] [p < .02]). An increase in metabolic acidosis could be observed in the lower temperature group: arterial pH 7.47 +/- 0.15 vs. 7.34 +/- 0.13 (p < .01); base deficit -3.7 +/- 6.7 vs. -8.2 +/- 4.9 mEq/L (p < .02). The oxygen extraction ratio remained unchanged: 0.39 +/- 0.10 vs. 0.38 +/- 0.10 (NS). CONCLUSIONS: These data show that VO2 was reduced to half of normal values during hypothermia. Active core rewarming produced an average 4.5% increase in VO2 per 1 degree C that was characterized by the wide variation observed in this metabolic response between different patients and for individual cases. Despite the rightward shift of P50 observed during rewarming (mainly due to the Bohr effect), no change was reflected on the oxygen extraction ratio.

Acidosis, Lactic↗

High-flow venovenous rewarming for the correction of hypothermia in a canine model of hypovolemic shock.

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.

Animals↗

An oesophageal thermal tube for rewarming in hypothermia.

Five dogs were cooled externally with ice-bags to rectal temperatures of 21.8-24.8 degrees C. Rewarming was performed with a specially constructed double-lumen oesophageal tube with circulating water at 42 degrees C. With this device, rewarming of the dogs to 30 degrees C took place in 60-102 min (mean 82 min). Up to a temperature of 31 degrees C (the "cardiac safety temperature"), the rise in blood temperature was 4.5 degrees C/h +/- 0.79 (s.d.). Calculation of a "rewarming efficiency index" showed an inverse relationship between surface area and temperature rise per hour. The efficiency of this rewarming method is comparable to that of peritoneal dialysis. No after-drop in temperature was observed and there were no other complications during these experiments. Rewarming with an oesophageal thermal tube is very simple and safe to use.

Animals↗

Deep accidental hypothermia and cardiac arrest--rewarming with forced air.

BACKGROUND: During the last two cold winters we have treated 5 severely hypothermic patients (temperature below 30 degrees C) with active external rewarming rather than with extracorporal circulation and heat exchanger. PATIENTS: Two patients were found in cardiac arrest, and 3 victims of mountain accidents suffered deep hypothermia without arrest. In one of them, ventricular fibrillation (VF) was converted successfully to a sinus rhythm at a core temperature of 25.9 degrees C. Both arrested patients developed an adequate hemodynamic state during resuscitation although they were at very low temperature. All the patients were warmed with a convective cover inflated with warm air of about 38 degrees C (Bair Hugger). The core temperature increased by approximately 1 degree C/h in all patients. During rewarming we observed neither an initial drop of the core temperature (afterdrop) nor cardiac arrhythmias. The outcome of all 5 patients was good without neurological sequelae. CONCLUSION: We conclude that external rewarming with forced air is a feasible alternative to cardiopulmonary bypass in severely hypothermic patients with electrical activity. This method can be used even in patients with VF because defibrillation can be successfully performed in deep hypothermia. Although after-drop during external rewarming is feared, we did not observe this phenomenon. Rewarming with forced air is inexpensive, easy to perform and direct access to the patient is possible at any time. It does not require heparinisation and can be used in hospitals where they do not have cardiopulmonary bypass facilities. Thus, this method is particularly useful in situations when the hypothermic patient cannot be transferred to a major medical center.

Accidents↗

Thermal increment provided by inhalation rewarming from hypothermia.

To quantify the core temperature gain derived from inhalation rewarming, 10 subjects were immersed in seawater (mean temperature 12 degrees C) until a 2 degree C drop in rectal temperature occurred, and were then rewarmed by breathing hot saturated air at 45 degrees C for 30 min. Each subject was rewarmed once breathing air and once rebreathing a controlled fraction of expired air adjusted to produce a hyperventilation of 50 l/min. After 30 min of rewarming mean rectal temperature had increased 0.39 degrees C in subjects breathing air compared with 0.77 degrees C in those hyperventilating (P less than 0.01). Corresponding gains in tympanic temperatures were 1.1 and 1.5 degrees C, respectively. Calculations indicate that the additional heat input with hyperventilation yielded a core (rectal) temperature gain of 5.1 X 10(-4) degrees C/l. It is concluded that each additional 10 l/min of ventilation of hot saturated air will increase the rate of core rewarming from hypothermia by approximately 0.3 degrees C/h.

Adult↗

Hyperemia prior to acute brain swelling during rewarming of patients who have been treated with moderate hypothermia for severe head injuries.

OBJECT: The goal of this study was to elucidate the optimal time for rewarming of patients who have been treated with hypothermia for severe head injury. METHODS: Eleven patients with severe head injuries who had been treated by hypothermia underwent transcranial Doppler (TCD) ultrasonography examinations. The patients were divided into two groups: Group A consisted of three patients in whom acute brain swelling occurred during the rewarming period and Group B was composed of eight patients who displayed no significant intracranial hypertension during or after hypothermia therapy. In all patients, the mean flow velocity of the middle cerebral artery (FV(MCA)) recorded transcranially and the mean flow velocity of the internal carotid artery (FV(ICA)), recorded high in the neck, were monitored at 24-hour intervals after the patient was admitted to the hospital. In Group A, the FV(MCA) was normal at 48 hours (maintenance state of hypothermia) in each patient, and abnormal increases and peak values (> 100 cm/second) occurred from 96 to 144 hours postinjury (rewarming period). The FV(ICA), which was monitored concurrently also varied as the FV(MCA) increased. The pulsatility indices in the arteries decreased at the time of the peak FV(MCZ). The enhanced FV(MCA) was consistent with hyperemia because of the low FV(MCA)/FV(ICA) ratios (< 3). Two patients in whom jugular venous oxygen saturation was monitored were found to have high values (> 80%), representing hyperemia. All intracranial pressures (ICPs) that lay within the normal range at 48 hours postinjury elevated acutely after the peak FV(MCA). In Group B, both FV(MCA) and FV(ICA) values were normal at 48 hours postinjury and remained stable throughout the rewarming period. Values of ICP were also maintained within the normal range until the patients were weaned from hypothermia therapy. CONCLUSIONS: Hyperemia, detectable by TCD ultrasonography, may serve as an index in the prediction of acute brain swelling, and rewarming should be terminated when such a hemodynamic phenomenon is observed.

Acute Disease↗

Changes of microvascular vasomotion and oxygen metabolism during cooling and rewarming period of cardiopulmonary bypass.

Microcirculation plays an important role in keeping a stable tissue metabolism during cardiopulmonary bypass (CPB). The relationship between microvascular vasomotion (MV) and total body's oxygen metabolism with temperature alteration during CPB remains unclear. Is there a relationship, or is the autoregulation a consequence of CO2, pressure and/or blood flow? The purpose of this study was to investigate the effect of temperature alteration on cutaneous MV and the total body's oxygen metabolism during CPB. Sixteen consecutive patients scheduled for elective cardiac valve replacement surgery were included in this study. The pump flow varied from 1.8-3.0 L/m(-2)min(-1) to maintain venous oxygen saturation above 65% and mean arterial blood pressure above 60 mmHg. At a nasopharyngeal temperature of 30 degrees C, oxygen consumption (VO2) and oxygen extraction (O2 ext) were measured during the cooling and rewarming periods. MV and skin microcircular flow (SMF) were monitored dynamically at the middle of two sides of the eyebrow with a laser Doppler flowmeter simultaneously VO2 and O2 ext at 30 degrees C were significantly lower during the cooling period (VO2, 49.9 +/- 17.7 mL/m(-2)/min(-1); O2 ext, 19.3 +/- 6.2%) than that during the rewarming period (VO2, 133.3 +/- 40.0 mL/m(-2)/min(-1); O2 ext, 35.2 +/- 9.2%) (p < .05). SMF was significantly depressed during CPB (p < .05). SMF during the cooling period (50.2% +/- 10.1%) was significantly less than that during the rewarming period (79.5% +/- 12.3%) (p < .05). MV was significantly less active during CPB than that before CPB (5.8 +/- 1.2 cyc/min) (p < .05), whereas there was no significant difference in MV between the cooling (3.7 +/- 1.8 cyc/min) and the rewarming period (4.1 +/- 1.5 cyc/min) and (p > .05). SMF and MV were depressed during hypothermic CPB, and there was some recovery during the rewarming period. Compared to baseline, SMF and MV were still significantly reduced during the warming period, indicating microvascular function was abnormal. Some measures should be taken for improvement of microvascular function during CPB.

Adult↗

Continuous arteriovenous rewarming: experimental results and thermodynamic model simulation of treatment for hypothermia.

We evaluated a technique for treating hypothermia that uses extracorporeal circulation but does not require heparin or pump assistance. Hypothermia to 29.5 degrees C was induced in eight anesthetized dogs, and thermistors placed in the pulmonary artery, liver, bladder, esophagus, rectum, muscle, and skin. Four experimental animals were rewarmed by creating a fistula which connected arterial and venous femoral lines to an interposed counter-current heat exchanger. External rewarming was used in four controls. Bleeding time (BT), coagulation profile (PT, PTT, TT), and cardiac output (CO) were measured during rewarming. Core temperature (T) rose significantly faster with CAVR (0.00001). Average time to rewarming was 45 min, vs. 4 hrs in controls. Haptoglobin, platelet, fibrinogen, and fibrin split product levels were unaffected. Continuous arteriovenous rewarming (CAVR) improved T, CO, BT, and coagulation profile faster than any method yet reported not requiring heparin or cardiac bypass. The application of CAVR in post-traumatic hypothermia warrants further investigation.

Animals↗

[Acral rewarming. II: Comparison of healthy probands and depressed patients].

The effect of local cooling on acral rewarming function was measured in healthy subjects and depressed patients. Although group comparison showed that acral rewarming is significantly slower in depressed patients, this parameter cannot be considered as specific for thermoregulatory disturbances in depression since there is marked overlap between groups. Comparison of the annual course was more informative. Annual variations in acral rewarming rate with sex specific differences were found in both groups. However, the variation with time of year was of greater amplitude in depressed patients. Furthermore, in the patient group an annual rhythm was present even in basal finger temperature. Significant March and October troughs in rewarming efficiency after local cooling were found in women (both groups). The greater proportion of depressed women, and the higher spring and autumn incidence of affective illness, may thus have a physiological correlate. The results are discussed in view of the relevance of the acral rewarming test in psychiatric practice and research, the seasonal changes in thermoregulatory measures in the light of a chronobiological approach to depression.

Adult↗

Rewarming from experimental hypothermia: comparison of heated aerosol inhalation, peritoneal lavage, and pleural lavage.

This study compares the thermal transfer and rewarming characteristics of heated aerosol inhalation (HAI) alone and combined with peritoneal lavage (PEL) or pleural lavage (PLL). Closed-system PEL and PLL are equally efficient at rewarming hypothermic dogs and do so at a rate approximating 6 degrees C/h/m2. Cardiovascular responses to PEL and PLL were similar. Serum electrolytes, protein, Hct, and arterial blood gases were comparable and little changed when compared in prehypothermia and postrewarming periods. HAI alone provides little heat for rewarming; more heat is realized from endogenous metabolism. Nevertheless, HAI's ease of use and possible selective cardiac rewarming characteristics argue for its inclusion with other methods of active rewarming. The use of PEL or PLL is governed by clinical circumstances.

Aerosols↗

Platelet sequestration during hypothermia in dogs treated with sulphinpyrazone and ticlopidine--reversibility accelerated after intra-abdominal rewarming.

During body cooling, a progressive thrombocytopenia is observed, with platelet sequestration mainly in the liver. Platelets return progressively to the circulation during rewarming. In this work the presence of platelet clumps is demonstrated by electron microscopy inside the hepatic sinusoids of dogs cooled to 20 degrees C by immersion in iced water. Such clumps were not found either before cooling or after body rewarming. Similar platelet clumps in the hepatic microcirculation were found in two other groups of dogs cooled and rewarmed as before, but previously treated with the antiaggregants sulphinpyrazone or ticlopidine. Another group of dogs was cooled and rewarmed by intra-abdominal circulation of physiological saline respectively at 4 degrees C and 40 degrees C. In these animals a similar decrease of circulating platelets was observed. However, just after rewarming was started, with the body temperature still at 22 degrees C, sequestered platelets came back abruptly to circulation. We conclude that hepatic platelet sequestration induced by hypothermia appears mainly due to local haemodynamic conditions.

Animals↗