Comparison of non-invasive blood pressure measurements on the arm and calf during cesarean delivery

OBJECTIVE

Shivering may occur in 75% of women undergoing spinal anesthesia for cesarean delivery and may render an automated noninvasive blood pressure (ANIBP) device incapable of determining blood pressurc (BP). When patients shiver under spinal anesthesia, the lower extremities do not exhibit the same involuntary muscle movements as do the upper extremities. This study was undertaken to determine if a correlation exists between ANIBP measurements in the arm and calf of women undergoing cesarean delivery under spinal anesthesia.

METHODS

We enrolled 73 women in this blinded, prospective study. Simultaneous arm and calf BP were measured with an ANIBP and differences between the two were determined.

RESULTS

We found significant differences between the average difference in systolic and in diastolic BP, no significant difference between the average mean BP, and a tendency for the systolic BP to be higher and the diastolic BP to be lower in the calf than in the arm; however, there was a large degree of variability among patients.

CONCLUSION

We conclude that there is a poor correlation between the BP measured by an ANIBP on the calf and one on the arm. In the parturient undergoing cesarean section, lower extremity BP as measured by an ANIBP does not correlate with the arm ANIBP and should not be used to assure fetal well being.

Endothermic heat production in honeybee winter clusters

In order to survive cold northern winters, honeybees crowd tightly together in a winter cluster. Present models of winter cluster thermoregulation consider the insulation by the tightly packed mantle bees as the decisive factor for survival at low temperatures, mostly ignoring the possibility of endothermic heat production. We provide here direct evidence of endothermic heat production by 'shivering' thermogenesis. The abundance of endothermic bees is highest in the core and decreases towards the surface. This shows that core bees play an active role in thermal control of winter clusters. We conclude that regulation of both the insulation by the mantle bees and endothermic heat production by the inner bees is necessary to achieve thermal stability in a winter cluster.

Eighty-four hours of sustained operations alter thermoregulation during cold exposure

PURPOSE; This study examined the effects of short-term (3.5 d) sustained military operations (SUSOPS) on thermoregulatory responses to cold stress.

METHODS

Ten men (22.8 +/- 1.4 yr) were assessed during a cold-air test (CAT) after a control week (control) and again after an 84-h SUSOPS (sleep = 2 h.d (-1), energy intake = approximately 1650 kcal.d(-1), and energy expenditure = approximately 4500 kcal.d(-1). CAT consisted of a resting subject (seminude) being exposed to an ambient temperature ramp from 25 degrees C to 10 degrees C during the initial 30 min of CAT, with the ambient temperature then remaining at 10 degrees C for an additional 150 min.

RESULTS

SUSOPS decreased (P< 0.05) body weight, % body fat, and fat-free mass by 3.9 kg, 1.6%, and 1.8 kg, respectively. During CAT, rectal temperature decreased to a greater extent (P< 0.05) after SUSOPS (0.52 +/- 0.09 degrees C) versus control (0.45 +/- 0.12 degrees C). Metabolic heat production was lower (P< 0.05) after SUSOPS at min 30 (55.4 +/- 3.3 W.m (-2)) versus control (66.9 +/- 4.4 W.m(-2)). Examination of the mean body temperature-metabolic heat production relationship indicated that the threshold for shivering was lower (P< 0.05) after SUSOPS (34.8 +/- 0.2 degrees C) versus control (35.8 +/- 0.2 degrees C). Mean weighted skin temperatures ( degrees C) were lower during the initial 1.5 h of CAT in SUSOPS versus control. Heat debt was similar between trials.

CONCLUSION

These results indicate that sustained (84-h) military operations leads to greater declines in core temperature, due to either a lag in the initial shivering response or heat redistribution secondary to an insulative acclimation.

A comparative study of three warming interventions to determine the most effective in maintaining perioperative normothermia

Perioperative hypothermia poses a challenge because of its deleterious effects on patient recovery. The current practice of applying two cotton blankets on patients during surgery is thought to be less ideal than using reflective insulation or forced-air warming. We studied 300 patients who underwent unilateral total knee replacement and were randomized equally to three groups: (a) the two-cotton-blanket group, (b) the one-reflective-blanket with one-cotton-blanket group, and (c) the forced-air-warming with one-cotton-blanket group. Tympanic temperature readings were taken before surgery in the induction room, on arrival at the recovery room, and at 10-min intervals until discharge from the recovery room. On arrival at the recovery room, the forced-air-warming group had significantly higher temperatures (adjusted for sex, age, and patient's induction room temperature) of 0.577 degrees C +/- 0.079 degrees C (95% confidence interval [CI], 0.427-0.726; P < 0.001) and 0.510 degrees C +/- 0.08 degrees C (95% CI, 0.349-0.672; P < 0.001) more than the reflective-blanket and two-cot-ton-blanket groups, respectively. The forced-air-warming group took a significantly (P < 0.001) shorter time of 18.75 min (95% CI, 13.88-23.62) to achieve a temperature of 36.5 degrees C in the recovery room as compared with 41.78 min (95% CI, 36.86-46.58) and 36.43 min (95% CI, 31.23-41.62) for the reflective-blanket and two-cotton-blanket groups, respectively. The reflective technology was less effective than using two cotton blankets, and the forced-air warming was most efficient in maintaining perioperative normothermia.

IMPLICATIONS

Perioperative hypothermia has deleterious effects on patient recovery. We found in patients having knee surgery that reflective technology was less effective than using two cotton blankets, whereas active surface warming with the forced-air method was most effective in maintaining normothermia.

Nitrous oxide decreases shivering threshold in rabbits less than isoflurane

BACKGROUND

Comparable minimum alveolar concentration (MAC) fractions of volatile anaesthetics produce similar thermoregulatory impairment. Nitrous oxide, however, decreases the vasoconstriction threshold less than sevoflurane or isoflurane. We tested the hypothesis that nitrous oxide also decreases shivering threshold less than isoflurane alone or in combination.

METHODS

Twenty-four rabbits were assigned randomly to one of three 0.3 MAC anaesthetic regimens: (i) nitrous oxide 69%; (ii) nitrous oxide 35% and isoflurane 0.3%; or (iii) isoflurane 0.6%. Body temperature was lowered by perfusing 10 degrees C water through a U-shaped thermode positioned in the colon. Shivering was evaluated by inspection.

RESULTS

The rabbits anaesthetized with nitrous oxide alone shivered at 37.0 (0.5) degrees C (P<0.01 vs other groups). In those given the nitrous oxide and isoflurane combination, the shivering threshold was 36.4 (0.5) degrees C and that in the isoflurane group was 35.9 (0.4) degrees C.

CONCLUSION

This study indicates that nitrous oxide reduces the shivering threshold less than isoflurane.

[Development of deep hypothermia in rats with limited motor activity]

Changes of the main organism functions (breathing frequency, heart rate and shivering) were investigated under hypothermia in two groups of rats. Animals of the first group were fixed rigidly on the special platform with fixing of head and limbs, and those of the second one--the rats, were placed in a punched cylindrical chamber, inside which they could move freely forward and back. In 2.5-3.0 hours after anaesthesia the rats were placed in a refrigerator (-5 degrees C) until they stop breathing. Cessation of breathing of the first group rats occurred in 1.7 +/- 0.3 hours from the beginning of cooling at body temperature 17.3 +/- 0.6 degrees C and the brain temperature 15.7 +/- 0.5 degrees C. In the second group, a prolonged activation of the frequency of breathing, heart rate and intensity of electrical activity of muscles during 2.5-3.0 hours, was observed. Only in 4.5-5.0 hours, the breathing stopped at rectal temperature 12.3 +/- 1.1 degrees C and the brain temperature 12.9 +/- 0.9 degrees C. In these animals, the time of survival in the cold environment increased considerably and the temperature thresholds of the termination of breathing were lowered. Thus, the activation in the thermo-regulative muscle tone and in shivering muscles provides the most effective resistance against cooling of rats, reducing a surface of heat, dissipation and keeping the temperature of internal areas of body.

The influence of active warming on signal quality of pulse oximetry in prehospital trauma care

Victims of trauma such as contusions and simple fractures are usually transported by paramedics. Because many victims are intoxicated with alcohol or other drugs, they are vulnerable to some risk of inadequate respiration. Thus, their oxygenation is monitored by noninvasive pulse oximetry. We tested the hypothesis that active warming of the whole body during transport to the hospital can improve the reliability of arterial oxygen saturation (SpO(2)) monitoring. Twenty-four trauma patients transported to hospital were included in the study and randomly assigned to two groups: one group (n = 12) was covered with normal wool blankets, and the other group (n = 12) was treated with resistive heating blankets during transport. We recorded core temperature, shivering, skin temperature at the forearm and finger, SpO(2), and hemodynamic variables. Before randomization, both groups were comparable. On arrival at the hospital, the actively warmed patients had significantly warmer core (36.1 +/- 0.3 degrees C versus 35.5 +/- 0.3 degrees C; P < 0.001) and skin (34.1 +/- 1.5 degrees C versus 24.9 +/- 1.4 degrees C; P < 0.001) temperatures. In the actively warmed group, the pulse oximeter had significantly fewer alerts (31 versus 58) and a significantly less time of malfunction (146 +/- 42 s versus 420 +/- 256 s) and provided more constant measurements in the actively warmed group (P < 0.001). In this study we showed that active warming improves pulse oximeter monitoring quality in trauma patients during transport to the hospital.

IMPLICATIONS

Clinical trials show that pulse oximeter signal quality is limited by hypothermia. In this study we show that active whole-body warming of trauma victims improves monitoring quality during transport to the hospital.

The emerging role of induced hypothermia in the management of acute stroke

Current treatment of acute stroke remains unsatisfactory. This review presents experimental and clinical data which suggest that mild induced hypothermia could be a potent and practicable neuroprotective treatment of acute ischaemic stroke and intracerebral haemorrhage. Hypothermia, if proven to be safe, effective and widely practicable in patients with acute stroke, could have an enormous positive impact on reducing the burden of stroke worldwide. Critical issues that will need to be considered in a well designed randomised controlled trial of induced hypothermia in acute stroke patients are discussed.

Effect of age and cold exposure on morphofunctional characteristics of skeletal muscle in neonatal pigs

Muscular changes accompanying and/or promoting the rapid postnatal improvement of the thermogenic efficiency of shivering were investigated in piglets. Animals were obtained at birth or killed after 5 days at thermoneutrality (34-30 degrees C) or in the cold (24-15 degrees C), to stimulate intense shivering thermogenesis. Fast-twitch-glycolytic (longissimus lumborum) and slow-twitch-oxidative (rhomboid) muscles were prepared for electron microscopic examination and chemical measurements. Muscle-specific changes in energy stores and metabolism were observed after birth, including the switch from glycogen to lipids and variation of the lactate/pyruvate ratio corresponding to the progressive acquisition of the metabolic type of the mature muscles. There was major age-related and/or cold-induced development of the structures involved in excitation-contraction coupling (triadic profiles, +80% in the cold), oxidative metabolism (number of lipid droplets, +81% with age in the cold; number of mitochondria, +29% with age or cold; surface of mitochondrial inner membranes, +18% with age and +32% in the cold) and contraction potential (myofibril volume, +62% with age). In contrast, neither age nor cold affected capillary volume density and capillary-to-fibre ratio. The observed changes reflect the immaturity and remarkable plasticity of piglet skeletal muscle and are likely to underlie its enhanced capacity for shivering thermogenesis after birth.

Upright posture reduces thermogenesis and augments core hypothermia

We recently reported that baroreceptor-mediated reflexes modulate thermoregulatory vasoconstriction during lower abdominal surgery. Accordingly, we examined the hypothesis that postural differences and the related alterations in baroreceptor loading similarly modulate the thermogenic (i.e., shivering) response to hypothermia in humans. In healthy humans (n = 7), cold saline was infused IV (30 mL/kg at 4 degrees C) for 30 min to decrease core temperature. Each participant was studied on 2 separate days, once lying supine and once sitting upright. Tympanic membrane temperature and oxygen consumption were monitored for 40 min after each saline infusion. The decrease in core temperature upon completion of the infusion in the upright posture position was 1.24 degrees C +/- 0.07 degrees C, which was significantly greater than the 1.02 degrees C +/- 0.06 degrees C seen in the supine position. The core temperature was reduced by 0.59 degrees C +/- 0.07 degrees C in the upright position but only by 0.37 degrees C +/- 0.05 degrees C in the supine position when the increase in oxygen consumption signaling thermogenic shivering occurred. Thus, the threshold temperature for thermogenesis was significantly less in the upright than the supine position. The gain of the thermogenic response did not differ significantly between the positions (363 +/- 69 mL. min(-1). degrees C(-1) for upright and 480 +/- 80 mL. min(-1). degrees C(-1) for supine). The skin temperature gradient was significantly larger in the upright than in the supine posture, suggesting that the peripheral vasoconstriction was augmented by upright posture. Plasma norepinephrine concentrations increased in response to cold saline infusion under both conditions, but the increase was significantly larger in the upright than in the supine posture. Baroreceptor unloading thus augments the peripheral vasoconstrictor and catecholamine response to core hypothermia but simultaneously reduces thermogenesis, which consequently aggravated the core temperature decrease in the upright posture.

IMPLICATIONS

Upright posture attenuates the thermogenic response to core hypothermia but augments peripheral vasoconstriction. This divergent result suggests that input from the baroreceptor modifies the individual thermoregulatory efferent pathway at a site distal to the common thermoregulatory center or neural pathway.

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.

Shivering endurance and fatigue during cold water immersion in humans

An important component of survival time during cold exposure is shivering endurance. Nine male and three female healthy and fit subjects [mean (SD) age 24.8 (6.3) years, body mass 71.7 (13.2) kg, height 1.75 (0.10) m, body fat 22.7 (7.4)%] were immersed to the upper chest level in cold water for periods ranging from 105 to 388 min on two occasions to test a prediction of shivering endurance. The water was cooled from 20 to 8 degrees C during the first 15 min of immersion and subsequently rewarmed (<20 degrees C) to elicit a near constant submaximal shivering response. The data were divided according to moderate (M) and high (H) levels of shivering intensity. Respective mean total immersion times were 250 (75) and 199 (80) min ( P=0.086) at different average shivering intensities of 61 (10) and 69 (8)% relative to maximal shivering ( P<0.001). Blood plasma glucose concentration increased during the immersion [from 3.44 (0.54) pre- to 3.94 (0.60) mmol x l(-1) post-immersion ( P=0.037)] and levels were higher during M ( P=0.012). When compared to a model prediction of shivering endurance, shivering activity continued well beyond the predicted endurance times in 18 out of the 24 trials. The average rates of oxygen consumption over the entire immersion period were lower ( P=0.002) during M [0.93 (0.20) l x min(-1)] compared to H [1.05 (0.21) l x min(-1)), and while these rates did not change during the last 90 min of immersion, there was an increase in fat oxidation. There were no trial differences in the average esophageal (T(es)) and mean skin temperatures during the entire immersion period (36.0 and 18.0 degrees C, respectively), yet T(es) decreased ( P=0.003) approximately 0.4 degrees C during the last 90 min of immersion. When the shivering intensity was normalized to account for this decrease, a significant downward trend of approximately 17% x h(-1) in the normalized shivering intensity was found after the predicted end of shivering endurance. These results suggest that shivering drive, and not shivering intensity per se, decreased during the latter stages of the immersion. Underlying mechanisms such as fatigue and habituation for this diminishing cold sensitivity are discussed.

[Severe hypothermia associated with cesarean section under spinal anesthesia]

Temperature monitoring and prevention of hypothermia are rarely used during spinal anaesthesia for caesarean section because hypothermia risk is considered very low. However, in same conditions, we observed two cases of severe hypothermia. We report these two cases and discuss the effects of spinal anaesthesia on thermoregulatory system. Hypothermia seems explained by the effects of perimedullar anaesthesia that decrease the shivering and the vasoconstriction thresholds. These effects are potentiated by morphinomimetic adjunction. At last, we recall prophylactics measures.

[Incidence of postoperative shivering in relation to the time of sevoflurane discontinuation]

OBJECTIVES

We aimed to determine whether early termination of sevoflurane administration lowers the incidence of postanesthetic shivering.

MATERIAL AND METHODS

Eighty ASA I-III patients were randomized to two groups of 40 (Group A and Group B). All were premedicated with oral bromazepam. Fentanyl (2 micrograms/Kg), propofol (2.5 mg/Kg) and atracurium (0.5 mg/Kg) were used for induction. Anesthesia was maintained with sevoflurane in 60% N2O in oxygen at 1 maximum alveolar concentration, with boluses of fentanyl and atracurium on demand. Sevoflurane administration was terminated 30 minutes before awakening in group A and 10 minutes before awakening in group B. After termination, 60% N2O in oxygen was used in both groups. Mean blood pressure, heart rate and peripheral and core temperatures were measured at 5 minutes intervals during surgery. Postoperative shivering was recorded until one hour after awakening.

RESULTS

Patient characteristics and duration of anesthesia were similar in both groups. The incidence of shivering was significantly lower in group A (4%) than in group B (57%). No significant differences were observed in other variables.

CONCLUSIONS

The important observation in this study was that the incidence of postoperative shivering in group A was lower than in group B and lower than the incidences reported in other similar studies.

Postanaesthetic shivering: epidemiology, pathophysiology, and approaches to prevention and management

Along with nausea and vomiting, postanaesthetic shivering is one of the leading causes of discomfort for patients recovering from general anaesthesia. The distinguishing factor during electromyogram recordings between patients with postanaesthetic shivering and shivering in fully awake patients is the existence of clonus similar to that recorded in patients with spinal cord transection. Clonus coexists with the classic waxing and waning signals associated with cutaneous vasoconstriction (thermoregulatory shivering). The primary cause of postanaesthetic shivering is peroperative hypothermia, which sets in because of anaesthetic-induced inhibition of thermoregulation. However, shivering associated with cutaneous vasodilatation (non-thermoregulatory shivering) also occurs, one of the origins of which is postoperative pain. Apart from causing discomfort and aggravation of pain, postanaesthetic shivering increases metabolic demand proportionally to the solicited muscle mass and the cardiac capacity of the patient. No link has been demonstrated between the occurrence of shivering and an increase in cardiac morbidity, but it is preferable to avoid postanaesthetic shivering because it is oxygen draining. Prevention mainly entails preventing peroperative hypothermia by actively rewarming the patient. Postoperative skin surface rewarming is a rapid way of obtaining the threshold shivering temperature while raising the skin temperature and improving the comfort of the patient. However, it is less efficient than certain drugs such as meperidine, clonidine or tramadol, which act by reducing the shivering threshold temperature.

[Goose flesh and cold sensation. Symptoms of visceral epilepsy]

Goose flesh and cold shiver can be ictal signs of visceral epilepsies. These visceral epilepsies may occur with isolated ictal signs during a simple partial seizure or in combination with other autonomic signs or in complex partial seizures. Because of the unusual features of the ictal symptomatology, these visceral epilepsies often are masked and wrongly diagnosed as nonepileptic events, e.g., somatoform disorders. Five cases are reported with case history, neurological findings, and results of electroencephalography, MEG, and imaging. Interestingly, patients did not suffer from tumoral epilepsies and the epileptic focus was lateralized to the left (dominant) temporal lobe.

Physiological responses to cold exposure in men: a disabled submarine study

A disabled submarine (DISSUB) lacking power and/or environmental control will become cold, and the ambient air may become hypercapnic and hypoxic. This study examined if the combination of hypoxia, hypercapnia, and cold exposure would adversely affect thermoregulatory responses to acute cold exposure in survivors awaiting rescue. Seven male submariners (33 +/- 6 yrs) completed a series of cold-air tests (CAT) that consisted of 20-min at T(air) = 22 degrees C, followed by a linear decline (1 degrees C x min(-1)) in T(air) to 12 degrees C, which was then held constant for an additional 150-min. CAT were performed under normoxic, normocapnic conditions (D0), acute hypoxia (D1, 16.75% O2), after 4 days of chronic hypoxia, hypercapnia and cold (D5, 16.75% O2, 2.5% CO2, 4 degrees C), and hypoxia-only again (D8, 16.75% O2). The deltaTsk during CAT was larger (P < 0.05) on D0 (-5.2 degrees C), vs. D1 (-4.8 degrees C), D5 (-4.5 degrees C), and D8 (-4.4 degrees C). The change (relative to 0-min) in metabolic heat production (deltaM) at 20-min of CAT was lower (P < 0.05) on D1, D5, and D8, vs. D0, with no differences between D1, D5 and D8. DeltaM was not different among trials at any time point after 20-min. The mean body temperature threshold for the onset of shivering was lower on D1 (35.08 degrees C), D5 (34.85 degrees C), and D8 (34.69 degrees C), compared to D0 (36.01 degrees C). Changes in heat storage did not differ among trials and rectal temperature was not different in D0 vs. D1, D5, and D8. Thus, mild hypoxia (16.75% F1O2) impairs vasoconstrictor and initial shivering responses, but the addition of elevated F1CO2 and cold had no further effect. These thermoregulatory effector changes do not increase the risk for hypothermia in DISSUB survivors who are adequately clothed.

Shiver suppression using focal hand warming in unanesthetized normal subjects

BACKGROUND

A decrease of 1 or 2 degrees C in core temperature may provide protection against cerebral ischemia. However, during corporeal cooling of unanesthetized patients, the initiation of involuntary motor activity (shiver) prevents the reduction of core temperature. The authors' laboratory previously showed that focal facial warming suppressed whole-body shiver. The aim of the current study was to determine whether the use of hand warming alone could suppress shiver in unanesthetized subjects and hence potentiate core cooling.

METHODS

Subjects (n = 8; healthy men) were positioned supine on a circulating water mattress (8-15 degrees C) with a convective-air coverlet (14 degrees C) extending from their necks to their feet. A dynamic protocol was used in which focal hand warming was used to suppress involuntary motor activity, enabling noninvasive cooling to decrease core temperatures. The following parameters were monitored: (1) heart rate; (2) blood pressure; (3) core temperature (rectal, tympanic); (4) cutaneous temperature and heat flux; (5) subjective shiver level (SSL scale 0-10) and thermal comfort index (scale 0-10); (6) metabolic data (n = 6); and (7) electromyograms.

RESULTS

During cooling without hand warming, involuntary motor activity increased until it was widespread. After subjects reported whole-body shiver (SSL > or = 7), applied hand warming, in all cases, reduced shiver levels (SSL < o r= 3), decreased electromyographic root mean square amplitudes, and allowed core temperature to decrease from 37.0 +/- 0.2 to 35.9 +/- 0.5 degrees C (measured rectally).

CONCLUSIONS

Focal hand warming seems to be valuable in minimizing or eliminating the need to suppress involuntary motor activity pharmacologically when it is desired to induce or maintain mild hypothermia; it may be used in conjunction with facial warming or in cases in which facial warming is contraindicated.

Hypothalamic region facilitating shivering in rats

Although the posterior part of the hypothalamus has long been considered important for thermoregulatory shivering, it is unknown whether the neurons there or the passing fibers are implicated in the response. Exposure of urethane-anesthetized rats to cold (15-21 degrees C) elicits shivering. An injection of muscimol (0.5 mM), a GABA(A) receptor agonist, into the medial part of the hypothalamus, including the dorsomedial and posterior nuclei, suppressed the cold-induced shivering. This result suggests that neurons having an excitatory effect on shivering are in this region of the hypothalamus.