THE SIGNIFICANCE OF FACIAL SKIN TEMPERATURE IN THE CHEMICAL HEAT REGULATION OF PREMATURE INFANTS

Intra-operative temperature monitoring with cutaneous zero-heat- flux-thermometry in comparison with oesophageal temperature: A prospective study in the paediatric population

BACKGROUND

Maintenance of thermal homeostasis is of crucial importance in the anesthetized pediatric patient. Gold-standard methods for central core temperature measurement are however inappropriately invasive and impractical in daily practice. The SpotOn sensor uses zero-heat-flux thermometry technology and claims to bypass the invasiveness of classical methods and still accurately display central core temperatures. Up to date no formal analysis of this method in children has taken place.

AIMS

The primary objective was to assess the accuracy in comparison with esophageal temperature; the secondary objective concerned the safety of the SpotOn sensor in the pediatric patients.

METHODS

Fifty-four children aged 1-12 years with an American Society of Anesthesiology classification I or II scheduled to undergo elective surgical procedures under general anesthesia for a minimum of 30 minutes were included. Exclusion criteria included: fragile forehead skin, procedures impeding proper SpotOn placement, thoracoscopic or gastroesophageal procedures, coagulopathy, hemodynamic instability, or vasoactive medication use. After sevoflurane induction, an esophageal temperature probe was placed in the lower third of the esophagus, and a SpotOn sensor on the lateral forehead. Temperatures were recorded in pairs per 1 minute intervals. Temperatures were subjected to bias analysis with 0.5°C as the a priori established clinical significance cutoff.

RESULTS

Bland-Altman analysis revealed the two methods differed on average 0.14°C (95% limits of agreement: -0.39 to 0.66), with 89.5% of the differences being under 0.5°C. No significant differences could be found between the two methods for the established 0.5°C cutoff. Linear regression analysis determined the following linear regression equation: 0.837x + 5.86 (R²  = 0.738). Lin's concordance correlation coefficient of 0.83 (95% CI: 0.81-0.84). No complications were observed with the use of the SpotOn sensor.

CONCLUSION

SpotOn revealed itself as accurate as an esophageal temperature probe when estimating central core temperatures under ideal conditions and over a narrow range of temperatures. No adverse effects were observed with the use of the SpotOn sensor.

The role of CO(2) and central chemoreception in the control of breathing in the fetus and the neonate

Central chemoreception is active early in development and likely drives fetal breathing movements, which are influenced by a combination of behavioral state and powerful inhibition. In the premature human infant and newborn rat ventilation increases in response to CO(2); in the rat the sensitivity of the response increases steadily after ∼P12. The premature human infant is more vulnerable to instability than the newborn rat and exhibits periodic breathing that is augmented by hypoxia and eliminated by breathing oxygen or CO(2) or the administration of respiratory stimulants. The sites of central chemoreception active in the fetus are not known, but may involve the parafacial respiratory group which may be a precursor to the adult RTN. The fetal and neonatal rat brainstem-spinal-cord preparations promise to provide important information about central chemoreception in the developing rodent and will increase our understanding of important clinical problems, including The Sudden Infant Death Syndrome, Congenital Central Hypoventilation Syndrome, and periodic breathing and apnea of prematurity.

Thermoregulatory defense mechanisms

Core body temperature is normally tightly regulated by an effective thermoregulatory system. Thermoregulatory control is sometimes impaired by serious illness, but more typically remains intact. The primary autonomic defenses against heat are sweating and active precapillary vasodilation; the primary autonomic defenses against cold are arteriovenous shunt vasoconstriction and shivering. The core temperature triggering each response defines its activation threshold. Temperatures between the sweating and vasoconstriction thresholds define the inter-threshold range. The shivering threshold is usually a full 1 degrees C below the vasoconstriction threshold and is therefore a "last resort" response. Both vasoconstriction and shivering are associated with autonomic and hemodynamic activation; and each response is effective, thus impeding induction of therapeutic hypothermia. It is thus helpful to accompany core cooling with drugs that pharmacologically induce a degree of thermal tolerance. No perfect drug or drug combination has been identified. Anesthetics, for example, induce considerable tolerance, but are rarely suitable. Meperidine-especially in combination with buspirone-is especially effective while provoking only modest toxicity. The combination of buspirone and dexmedetomidine is comparably effective while avoiding the respiratory depression association with opioid administration.

Temperature monitoring and perioperative thermoregulation

Most clinically available thermometers accurately report the temperature of whatever tissue is being measured. The difficulty is that no reliably core-temperature-measuring sites are completely noninvasive and easy to use-especially in patients not undergoing general anesthesia. Nonetheless, temperature can be reliably measured in most patients. Body temperature should be measured in patients undergoing general anesthesia exceeding 30 min in duration and in patients undergoing major operations during neuraxial anesthesia. Core body temperature is normally tightly regulated. All general anesthetics produce a profound dose-dependent reduction in the core temperature, triggering cold defenses, including arteriovenous shunt vasoconstriction and shivering. Anesthetic-induced impairment of normal thermoregulatory control, with the resulting core-to-peripheral redistribution of body heat, is the primary cause of hypothermia in most patients. Neuraxial anesthesia also impairs thermoregulatory control, although to a lesser extent than does general anesthesia. Prolonged epidural analgesia is associated with hyperthermia whose cause remains unknown.

The interaction between sleep and thermoregulation in adults and neonates

The interaction between sleep and thermoregulation leads to different thermoregulatory responses depending on the sleep stage and alterations in sleep when in a cool or warm environment. In the human adult, differences in thermoregulatory efficiency during rapid eye movement (REM) sleep and slow wave sleep (SWS) are less pronounced compared to other mammals: although thermoregulatory processes persist in REM sleep, they are less efficient than during SWS. Cold and warm loads disturb the efficiency and structure of sleep. The duration of REM sleep and (to a lesser extent) of SWS decreases. In contrast, pre-sleep warm loads enhance SWS and improve sleep continuity. This procedure may promote and maintain sleep in depressed patients, whose sleep and body temperature rhythms are modified. In contrast to adults, homeothermic processes in neonates are maintained or even enhanced during active sleep (AS) when compared to quiet sleep (QS). Sleeping in a cool environment increases the duration of AS at the expense of QS. As a result, the thermoregulatory function overcomes the need to conserve energy that would otherwise lead to increased QS. An interaction between sleep, respiration, and thermoregulation may be involved in Sudden Infant Death Syndrome: an alteration in the thermal balance may perhaps induce respiration instability, especially during AS.

Nonmalignant hyperthermia on induction of anesthesia in a pediatric patient undergoing bidirectional Glenn procedure

We report a case of severe hyperthermia in a 6-month-old boy with a single ventricle, dextrocardia, asplenia, and transposition of the great arteries, during induction of anesthesia on three separate occasions. To our knowledge, this is the first case reported of repeated intraoperative hyperthermia not related to malignant hyperthermia, infection, neuroendocrine tumor, or iatrogenic causes (e.g., anticholinergic blockade or warming devices). The severe hyperthermia may be secondary to the medications given before and during induction and/or the stress of the induction. Among the induction medications given during the three episodes, fentanyl is the most likely contributing drug. Human data indicate that opioids increase the sweating threshold and decrease the vasoconstriction and shivering thresholds. The medications could cause a widening in the thermoregulation interthreshold and the stress could induce nonshivering thermogenesis.

Skin derivative control of thermal environment in a closed incubator

Defining a thermoneutral environment remains difficult because thermoneutrality depends on both physical and physiological factors. A servocontrolled skin temperature derivative (SCS) heating device has been designed to control the thermal environment in closed incubators without the necessity of setting an air or skin reference temperature. The thermal environment obtained with the SCS program is controlled only by the neonate's skin temperature changes. For each neonate, the program allows the attainment of a specific individual thermal equilibrium (Teq). Although the mean value of the thermal equilibrium level measured on 29 neonates does not differ significantly from the neutral air temperature defined from the charts of other researchers, individual values of Teq differed greatly among neonates of similar birthweight and postnatal age. When compared with on/off heating programs, the SCS system permits greater quiet sleep occurrence and seems to provide an optimal thermal environment. The results suggest that the skin temperature derivative heating program takes into account both the ambient and physiological factors affecting body temperature regulation of each neonate.

Consequences of getting the head covered during sleep in infancy

OBJECTIVE

To study the consequences of getting the head covered by bedding (fiber quilt) on carbon dioxide (CO2) accumulation around the face, behavior, and physiologic responses during prone and supine sleep in infants to add understanding to why victims of sudden infant death syndrome are often found under the bedding. METHPDOLOGY: Of 33 healthy term, usually nonprone sleeping infants, behavior and computerized polysomnography were successfully recorded for 30 during prone and supine sleep at 21/2 months and for 23 prone and 25 supine at 5 months.

RESULTS

For both ages and body positions, covering the head resulted in significant CO2 accumulation around the face, fewer apneas (3 to 10 seconds), shorter duration of apneas after sighs, higher heart and respiratory rates, and peripheral skin temperature. Differences were generally greater at 21/2 than at 5 months. While covered, the prone position was associated with higher CO2 levels close to the face, slightly higher transcutaneous PCO2, and higher heart rates and peripheral skin temperatures than the supine position. In the supine position 23% were able to remove the cover from the head at 21/2 and 60% at 5 months, whereas only 1 infant of 5 months managed to remove the cover when prone.

CONCLUSIONS

The observed responses are consistent with a potential for distress when the head is covered, particularly when placed prone. Probably most important with respect to sudden infant death syndrome is the infants' inability to remove the bedding from the head upon awakening from prone sleep.

Behaviour and physiological responses during prone and supine sleep in early infancy

AIMS

To study the effect of prone and supine sleep on infant behaviour, peripheral skin temperature, and cardiorespiratory parameters to aid understanding of why prone sleeping is associated with an increased risk of sudden infant death syndrome.

METHODS

Of 33 enrolled infants, 32 were studied at 2.5 and 28 at 5 months of age. A computer aided multichannel system was used for polysomnographic recordings. Behaviour was charted separately.

RESULTS

Prone REM (active) sleep was associated with lower frequencies of short arousals, body movements and sighs, and a shorter duration of apnoeas than supine REM sleep at both ages. At 2.5 months there were less frequent episodes of periodic breathing during prone sleep in non-REM (quiet) and REM sleep. Heart rate and peripheral skin temperature were higher in the prone position during both sleep states at both ages.

CONCLUSIONS

The observation of decreased variation in behaviour and respiratory pattern, increased heart rate, and increased peripheral skin temperature during prone compared with supine sleep may indicate that young infants are less able to maintain adequate respiratory and metabolic homoeostasis during prone sleep.

Body temperature regulation in the newborn infant: interaction with sleep and clinical implications

Thermoregulation in newborn infant differs from that of adult. Comparisons between sleep stages show that, during rapid eye movements (REM) sleep, the impairment of thermoregulatory responses in adult is not observed in newborn. Both behavioral and autonomic temperature regulations are always operative in the range of air temperatures usually imposed. The interaction between sleep and thermoregulation seems to be less important in newborns than in adults, suggesting that sleep processes are well protected, reducing the probability of occurrence of central dysfunction. According to the model describing thermoregulation during sleep on the basis of changes in the hierarchical dominance of brain structures, either the influence of diencephalic structures is never depressed in REM sleep or the functional autonomy of the rhombencephalon is still relevant in the immature encephalon of the newborn. The thermoregulatory model also allows understanding of inter-individual differences in thermoregulation and levels of thermoneutrality. An attempt has also been made to learn the role of heat stroke in the production of sudden infant death syndrome when body heat loss is hampered.

Influence of body temperature on thyrotropic hormone release and lipolysis in the newborn infant

The present study investigated possible interactions between body temperature, lipolysis and thyrotropin (TSH), the only hormone with a documented lipolytic effect in vitro in newborn infants. Healthy infants were either nursed in the usual way (n = 18) or protected from a decrease in body temperature (n = 17) during the first postnatal hour. The infants' axillary temperatures were measured immediately after birth and after 10 and 60 min. Blood samples were collected from the umbilical vein and from the infants 10 and 60 min after birth for analysis of TSH, glycerol, free fatty acids, 3-OH-butyric acid and glucose. We found that the mean (+/- SD) infant axillary temperature was 37.6 +/- 0.4 degrees C immediately after birth. In the routinely nursed infants, body temperature decreased to 37.0 +/- 0.5 degrees C at 10 min (p = 0.01) and to 36.6 +/- 0.4 degrees C at 60 min (p = 0.01); the cold-protected infants maintained their fetal temperature at 60 min of age. There was a four-fold increase in plasma TSH levels at 10 min, independent of the infant's body temperature, and the hormone level remained invariably high at 60 min. Plasma glycerol levels increased progressively at 10 min (p = 0.01) and 60 min (p = 0.01) in both infant groups, but were higher (p = 0.02) in the routinely nursed infants at 60 min. No significant relationship was found between TSH and glycerol levels. Infant body temperature did not affect the levels of free fatty acids, 3-OH-butyric acid or glucose. We conclude that the change in environmental temperature as a result of extrauterine adaptation causes thermal stimulation of the infant's body surface which leads to activation of the hypothalamic-pituitary TSH axis, resulting in maximal TSH release, and thus to induction of the lipolytic process. A decrease in body temperature may be an additive stimulus for further enhancement of lipolysis.

Does thermoregulatory feeding occur in newborn infants? A novel view of the role of brown adipose tissue thermogenesis in control of food intake

The physiological significance of the extensive deposits of brown adipose tissue (BAT) in newborn human infants has been the subject of much experimentation and discussion. Because of its large thermogenic capacity, its function has usually been viewed as preparing the infant for producing heat in response to cold exposure at birth. Newborn infants are indeed capable of precise thermoregulation for a limited time over a rather limited range of ambient temperatures, from thermoneutrality (32-34 degrees C) down to common "room" temperatures (24-28 degrees C). During such mild "cold-exposure", in response to a decrease in their skin temperature, their sympathetic nervous system activity increases, and they can more than double their resting metabolic rate, principally by thermogenesis in their BAT. This review puts forward an entirely new role for BAT thermogenesis in the cyclic feeding pattern of newborn infants during their first months of life. BAT thermogenesis is proposed to be an integral element in a physiological thermoregulatory feeding control mechanism in which extended periods of very gradual cooling are interspersed with episodes of increased sympathetic nervous system activity, increased heating via BAT thermogenesis, arousal, and feeding. The cry with which the baby attracts its mother's attention is an integral part of the mechanism, as is the nutritive suckling reflex and the behavior of the mother. Initiation of feeding is attributed to a transient dip in blood glucose concentration that is due to stimulation of glucose utilization in the BAT. Termination of feeding is attributed to the high temperature brought about by the stimulated BAT thermogenesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Impaired ventilation in infants sleeping facedown: potential significance for sudden infant death syndrome

Although accidental suffocation has been suggested as a cause of sudden infant death syndrome in infants who are found prone with their faces straight down, the occurrence and effects on breathing of this position in living infants are unknown. We studied prone sleeping infants to see whether they will sleep with their faces straight down; whether they can spontaneously change from this position; the way that thermal stimuli or bedding softness influences this change; and whether rebreathing or airway obstruction occurs. We studied 11 healthy infants, aged 0.2 to 6 months, while they slept on soft and on firm bedding. Most infants slept facedown spontaneously or when turned to this position. All could turn their heads readily but slept facedown for variable periods. All infants put their faces straight down more often after cold than after warm stimuli. Obstructive apnea occurred only once, but rebreathing occurred in all subjects. When the infants were in the facedown position, inspired carbon dioxide was three times greater on soft than on hard bedding. End-tidal carbon dioxide partial pressure rose in all subjects while they were in the facedown position; in one infant, high end-tidal carbon dioxide partial pressure and desaturation occurred without signs of arousal. We conclude that infants sleeping facedown may occasionally have significant asphyxia; this sleep position may have a role in some infant deaths diagnosed as sudden infant death syndrome.

Design and performance of blanket heat shields for neonates

BACKGROUND

Several designs of plastic blanket heat shields are in use. This study was done to compare different designs for their efficiency in reducing heat loss.

METHODS

Four heat shield designs were tested by sequentially covering each of 14 infants (wt. 640-2,030 g) cared for under radiant warmers. The power consumption of the radiant warmers was measured as a surrogate for heat loss. All designs were tested for a total of 20 min on all infants. Results were calculated as percent change in power consumption from shield to shield. The most efficient design was further modified and evaluated in another group of 14 infants (wt. 700-1,180 g).

RESULTS

The relative reductions in power consumption were: no shield (control) -0%, a plastic foil over the side rails: -17%, a single layer close to the infant but excluding the head: -34%, the same as double layer -37% and the most efficient one, a single layer covering the whole infant -42%. A modification of this design, tested in the second group of infants, reduced power consumption by 13% (95% CI -5.9/-19.7), (p less than 0.004) when compared to the single layer covering the whole infant. It was tucked under the connecting tubes to the ventilator. It also reduced the risk for displacement and allowed for the endotracheal tube to be suctioned without removing the blanket.

CONCLUSION

Modifications of the design of heat shield blankets for infants resulted in significant increases in efficiency.

Providing warmth for preterm babies by a heated, water filled mattress

Seventeen healthy preterm babies had extra warmth provided in their cots by thermocontrolled, heated, water filled mattresses. As controls 17 babies of the same weight were nursed in air heated incubators. Both groups were studied for three weeks. No differences were found in minimal oxygen consumption (measured by indirect calorimetry), rectal and mean skin temperatures, or in daily weight gain. The babies were kept just as warm on the heated, water filled mattresses as in air heated incubators but the mattresses had the advantage of giving the mothers easy access to their babies.

The structure and function of brown adipose tissue in the neonate

Presented is a discussion of brown adipose cell structure as compared to that of the white adipose cell, the role which brown adipose tissue (BAT) plays in thermoregulation, the physiologic mechanisms which control BAT heat generation, and the proposed biochemical processes which are responsible for heat production in the cell. Based on the physiology of BAT thermogenesis, specific nursing measures to minimize cold stimuli are recommended.

Minimal oxygen consumption in infants cared for under overhead radiant warmers compared with conventional incubators

Infants under radiant warmers have large increases in insensible water loss compared with infants in single wall incubators. To answer the question of whether or not a minimal rate of oxygen consumption could be achieved under overhead radiant warmers, we measured oxygen consumption, carbon dioxide production, and abdominal skin, cheek, rectal, thigh, and environmental temperature in ten healthy newborn infants in incubators and radiant warmers, using each infant as his/her own control. The minimal VO2 ranged from 4.41 to 8.87 and from 4.35 to 9.06 cc/kg/minute in the incubator and radiant warmer, respectively. The differences were clearly not significant (paired Student t-test, P greater than 0.60). There were no significant differences between the respiratory quotients, VCO2, or abdominal skin, check, rectal or environmental temperatures. These data support the hypothesis that a thermoneutral environment can be provided with a radiant warmer and imply that large increases in insensible water loss can occur without affecting minimal oxygen consumption.