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Deb P, Das R, Bhattacharyya P. Focal hand warming for post-anaesthesia shivering control: A simple and safe non-pharmacological approach in resource limited-area. J Family Med Prim Care 2023; 12:3434-3436. [PMID: 38361880 PMCID: PMC10866233 DOI: 10.4103/jfmpc.jfmpc_1070_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/05/2023] [Accepted: 08/11/2023] [Indexed: 02/17/2024] Open
Abstract
Post-anaesthesia shivering is a common complication and has multiple deleterious effects. Sometimes multiple non-pharmacological interventions applied together may not control post-anaesthesia shivering adequately, necessitating the use of drugs in some cases. Hand warming is commonly used to warm up the body since time immemorial but its role in preventing post-anaesthesia shivering has not been evaluated. This case series describes the application of this simple and safe method of focal hand warming along with other non-pharmacological measures to suppress post-anaesthesia shivering, whereby possible use of drugs could be avoided.
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Affiliation(s)
- Prakash Deb
- Departments of Anaesthesiology, North East Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India
| | - Rituparna Das
- Departments of Obstetrics and Gynaecology, North East Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India
| | - Prithwis Bhattacharyya
- Departments of Anaesthesiology, North East Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India
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Luo W, Kramer R, de Kort Y, Rense P, van Marken Lichtenbelt W. The effects of a novel personal comfort system on thermal comfort, physiology and perceived indoor environmental quality, and its health implications - Stimulating human thermoregulation without compromising thermal comfort. INDOOR AIR 2022; 32:e12951. [PMID: 34724246 PMCID: PMC9298036 DOI: 10.1111/ina.12951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/17/2021] [Accepted: 10/13/2021] [Indexed: 06/13/2023]
Abstract
The classical textbook interpretation of thermal comfort is that it occurs when the thermoregulatory effort is minimized. However, stimulating human thermoregulatory systems may benefit health and increase body thermal resilience. To address this gap, we tested a novel personal comfort system (PCS) that targets only the extremities and the head, leaving the rest of the body exposed to a moderately drifting temperature (17-25°C). A randomized, cross-over study was conducted under controlled laboratory conditions, mimicking an office setting. Eighteen participants completed two scenarios, one with a PCS and another one without a PCS in 17-25°C ambient conditions. The results indicate that the PCS improved thermal comfort in 17-23°C and retained active thermoregulatory control. The torso skin temperature, underarm-finger temperature gradients, energy expenditure, substrate oxidations and physical activity were not affected by the PCS in most cases. Only slight changes in cardiovascular responses were observed between the two scenarios. Moreover, the PCS boosted pleasure and arousal. At 25°C, the PCS did not improve thermal comfort, but significantly improved air quality perceptions and mitigated eye strain. These findings suggest that human physiological thermoregulation can be stimulated without compromising thermal comfort by using a PCS that only targets the extremities in cold conditions.
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Affiliation(s)
- Wei Luo
- Department of Nutrition and Movement SciencesSchool of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Rick Kramer
- Department of Nutrition and Movement SciencesSchool of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
- Department of the Built EnvironmentEindhoven University of TechnologyEindhovenThe Netherlands
| | - Yvonne de Kort
- Department of Industrial Engineering and Innovation SciencesEindhoven University of TechnologyEindhovenThe Netherlands
| | - Pascal Rense
- Department of Nutrition and Movement SciencesSchool of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
| | - Wouter van Marken Lichtenbelt
- Department of Nutrition and Movement SciencesSchool of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands
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Abstract
Therapeutic hypothermia (TH) is a potent neuroprotective therapy in experimental cerebral ischemia, with multiple effects at several stages of the ischemic cascade. In animals, TH is so powerful that all preclinical stroke studies require strict temperature control. In humans, multiple clinical studies documented powerful protection with TH after accidental neonatal hypoxic-ischemic injury and global cerebral ischemia with return of spontaneous circulation after cardiac arrest. National and international guidelines recommend TH for selected survivors of global ischemia, with profound benefits seen. Recently, a study comparing target temperature 33-36°C failed to demonstrate significant effects in cardiac arrest patients. Additionally, clinical trials of TH for head trauma and stroke have so far failed to confirm benefit in humans despite a vast preclinical literature. Therefore, it is now critical to understand the fundamental explanation for the success of TH in some, but famously not all, clinical trials. TH in animals appears to work when used soon after ischemia onset; for a short duration; and at a deep target temperature.
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Han Z, Liu X, Luo Y, Ji X. Therapeutic hypothermia for stroke: Where to go? Exp Neurol 2015; 272:67-77. [PMID: 26057949 DOI: 10.1016/j.expneurol.2015.06.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/16/2015] [Accepted: 06/04/2015] [Indexed: 01/08/2023]
Abstract
Ischemic stroke is a major cause of death and long-term disability worldwide. Thrombolysis with recombinant tissue plasminogen activator is the only proven and effective treatment for acute ischemic stroke; however, therapeutic hypothermia is increasingly recognized as having a tissue-protective function and positively influencing neurological outcome, especially in cases of ischemia caused by cardiac arrest or hypoxic-ischemic encephalopathy in newborns. Yet, many aspects of hypothermia as a treatment for ischemic stroke remain unknown. Large-scale studies examining the effects of hypothermia on stroke are currently underway. This review discusses the mechanisms underlying the effect of hypothermia, as well as trends in hypothermia induction methods, methods for achieving optimal protection, side effects, and therapeutic strategies combining hypothermia with other neuroprotective treatments. Finally, outstanding issues that must be addressed before hypothermia treatment is implemented at a clinical level are also presented.
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Affiliation(s)
- Ziping Han
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Xiangrong Liu
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Yumin Luo
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China
| | - Xunming Ji
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China; Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China.
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Alfonsi P, Passard A, Guignard B, Chauvin M, Sessler DI. Nefopam and Meperidine Are Infra-Additive on the Shivering Threshold in Humans. Anesth Analg 2014; 119:58-63. [DOI: 10.1213/ane.0000000000000193] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
This review analyses whether skin temperature represents ambient temperature and serves as a feedforward signal for the thermoregulation system, or whether it is one of the body's temperatures and provides feedback. The body is covered mostly by hairy (non-glabrous) skin, which is typically insulated from the environment (with clothes in humans and with fur in non-human mammals). Thermal signals from hairy skin represent a temperature of the insulated superficial layer of the body and provide feedback to the thermoregulation system. It is explained that this feedback is auxiliary, both negative and positive, and that it reduces the system's response time and load error. Non-hairy (glabrous) skin covers specialized heat-exchange organs (e.g. the hand), which are also used to explore the environment. In thermoregulation, these organs are primarily effectors. Their main thermosensory-related role is to assess local temperatures of objects explored; these local temperatures are feedforward signals for various behaviours. Non-hairy skin also contributes to the feedback for thermoregulation, but this contribution is limited. Autonomic (physiological) thermoregulation does not use feedforward signals. Thermoregulatory behaviours use both feedback and feedforward signals. Implications of these principles to thermopharmacology, a new approach to achieving biological effects by blocking temperature signals with drugs, are discussed.
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Affiliation(s)
- A. A. Romanovsky
- Trauma Research Systemic Inflammation Laboratory (FeverLab) St. Joseph's Hospital and Medical Center Phoenix AZUSA
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Logan A, Sangkachand P, Funk M. Optimal management of shivering during therapeutic hypothermia after cardiac arrest. Crit Care Nurse 2012; 31:e18-30. [PMID: 22135340 DOI: 10.4037/ccn2011618] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Both pharmacological and nonpharmacological methods are used to control shivering in therapeutic hypothermia. An evidence-based protocol based on the most current research has been developed for the management of shivering during therapeutic hypothermia. Meperidine is the drug of choice and provides the greatest reduction in the shivering threshold. Other effective pharmacological agents recommended for reducing the threshold include dexmedetomidine, midazolam, fentanyl, and magnesium sulfate. In addition, skin counterwarming techniques, such as use of an air-circulating blanket, are effective nonpharmacological methods for reducing shivering when used in conjunction with medication. As a last resort, neuromuscular blocking agents are considered appropriate therapy for management of refractory shivering.
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Affiliation(s)
- Angela Logan
- Yale School of Nursing, Yale University, New Haven, Connecticut 06536-0740, USA.
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Presciutti M, Bader MK, Hepburn M. Shivering management during therapeutic temperature modulation: nurses' perspective. Crit Care Nurse 2012; 32:33-42. [PMID: 22298716 DOI: 10.4037/ccn2012189] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Therapeutic temperature modulation, which incorporates mild hypothermia and maintenance of normothermia, is being used to manage patients resuscitated after cardiac arrest. Methods of modulating temperature include intravenous infusion of cold fluids and surface or endovascular cooling. During this therapy, the shiver response is activated as a defense mechanism in response to an altered set-point temperature and causes metabolic and hemodynamic stress for patients. Recognition of shivering according to objective and subjective assessments is vital for early detection of the condition. Once shivering is detected, treatment is imperative to avoid deleterious effects. The Bedside Shivering Assessment Scale can be used to determine the efficacy of interventions intended to blunt thermoregulatory defenses and can provide continual evaluation of patients' responses to the interventions. Nurses' knowledge and understanding of the harmful effects of shivering are important to effect care and prevent injury associated with uncontrolled shivering.
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Abstract
PURPOSE OF REVIEW The review covers the main aspects of thermoregulation physiology and highlights the implications for therapeutic hypothermia trials. Prevention of shivering and other hypothermia side-effects is of key importance because controlling thermoregulatory responses may be essential for demonstrating neuro-protective properties of hypothermia in several pathologic conditions in which its role is still uncertain, such as in traumatic brain injury and stroke. RECENT FINDINGS Several recommendations and clinical reviews have been produced in the past 2 years about the application and feasibility of therapeutic hypothermia. Many drugs have been tested in healthy volunteers and anaesthetized patients to abolish shivering but the best protocol for managing side-effects has not yet been defined. A possible strategy might be to simultaneously apply physical methods, such as skin warming, and combination drug therapy. Different drug protocols can be applied, depending on the nature of the care setting. SUMMARY During moderate hypothermia treatment, conducted in an intensive care environment, shivering can be treated with sedatives, opioids (meperidine in particular), and α2-agonists, combined with active skin counter-warming. However, new randomized controlled clinical trials in intensive care patients are required to improve our knowledge regarding this treatment.
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Abstract
Therapeutic hypothermia is a means of neuroprotection well established in the management of acute ischemic brain injuries such as anoxic encephalopathy after cardiac arrest and perinatal asphyxia. As such, it is the only neuroprotective strategy for which there is robust evidence for efficacy. Although there is overwhelming evidence from animal studies that cooling also improves outcome after focal cerebral ischemia, this has not been adequately tested in patients with acute ischemic stroke. There are still some uncertainties about crucial factors relating to the delivery of hypothermia, and the resolution of these would allow improvements in the design of phase III studies in these patients and improvements in the prospects for successful translation. In this study, we discuss critical issues relating first to the targets for therapy including the optimal depth and duration of cooling, second to practical issues including the methods of cooling and the management of shivering, and finally, of factors relating to the design of clinical trials. Consideration of these factors should inform the development of strategies to establish beyond doubt the place of hypothermia in the management of acute ischemic stroke.
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Blowing hot and cold? Skin counter warming to prevent shivering during therapeutic cooling*. Crit Care Med 2009; 37:2106-8. [DOI: 10.1097/ccm.0b013e3181a5e4d8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Metabolic benefits of surface counter warming during therapeutic temperature modulation*. Crit Care Med 2009; 37:1893-7. [DOI: 10.1097/ccm.0b013e31819fffd3] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Therapeutic hypothermia and controlled normothermia in the intensive care unit: practical considerations, side effects, and cooling methods. Crit Care Med 2009; 37:1101-20. [PMID: 19237924 DOI: 10.1097/ccm.0b013e3181962ad5] [Citation(s) in RCA: 466] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hypothermia is being used with increasing frequency to prevent or mitigate various types of neurologic injury. In addition, symptomatic fever control is becoming an increasingly accepted goal of therapy in patients with neurocritical illness. However, effectively controlling fever and inducing hypothermia poses special challenges to the intensive care unit team and others involved in the care of critically ill patients. OBJECTIVE To discuss practical aspects and pitfalls of therapeutic temperature management in critically ill patients, and to review the currently available cooling methods. DESIGN Review article. INTERVENTIONS None. MAIN RESULTS Cooling can be divided into three distinct phases: induction, maintenance, and rewarming. Each has its own risks and management problems. A number of cooling devices that have reached the market in recent years enable reliable maintenance and slow and controlled rewarming. In the induction phase, rapid cooling rates can be achieved by combining cold fluid infusion (1500-3000 mL 4 degrees C saline or Ringer's lactate) with an invasive or surface cooling device. Rapid induction decreases the risks and consequences of short-term side effects, such as shivering and metabolic disorders. Cardiovascular effects include bradycardia and a rise in blood pressure. Hypothermia's effect on myocardial contractility is variable (depending on heart rate and filling pressure); in most patients myocardial contractility will increase, although mild diastolic dysfunction can develop in some patients. A risk of clinically significant arrhythmias occurs only if core temperature decreases below 30 degrees C. The most important long-term side effects of hypothermia are infections (usually of the respiratory tract or wounds) and bedsores. CONCLUSIONS Temperature management and hypothermia induction are gaining importance in critical care medicine. Intensive care unit physicians, critical care nurses, and others (emergency physicians, neurologists, and cardiologists) should be familiar with the physiologic effects, current indications, techniques, complications and practical issues of temperature management, and induced hypothermia. In experienced hands the technique is safe and highly effective.
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Abstract
BACKGROUND Induced hypothermia is a promising neuroprotective treatment for acute ischemic stroke. Data from both global and focal ischemia animal models have been encouraging. However, only a few small clinical studies have investigated its use in humans. OBJECTIVE To review the background, possible mechanisms of action, and the preclinical and clinical data supporting the neuroprotective role of induced hypothermia following acute ischemic stroke. METHODS A literature search was performed using the PubMed database. Only papers in English were reviewed. RESULTS/CONCLUSIONS Induced hypothermia is effective as a neuroprotectant in animal models of acute ischemic stroke. Its multimodal mechanism of action makes it a very attractive method of neuroprotection. Although human studies suggest it is safe and feasible, larger randomized controlled trials are necessary to address clinical efficacy and to refine the methods and parameters of induced hypothermia protocols.
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Affiliation(s)
- Marc A Lazzaro
- Rush University Medical Center, Department of Neurological Sciences, 1725 W. Harrison Street, Suite 1121, Chicago, IL 60612, USA.
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16
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Abstract
Temperature management in acute neurologic disorders has received considerable attention in the last 2 decades. Numerous trials of hypothermia have been performed in patients with head injury, stroke, and cardiac arrest. This article reviews the physiology of thermoregulation and mechanisms responsible for hyperpyrexia. Detrimental effects of fever and benefits of normalizing elevated temperature in experimental models are discussed. This article presents a detailed analysis of trials of induced hypothermia in patients with acute neurologic insults and describes methods of fever control.
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Abstract
Hypothermia is a potent neuroprotectant and induced hypothermia holds great promise as a therapy for acute neuronal injury. Thermoregulatory responses, most notably shivering, present major obstacles to therapeutic temperature management. A review of thermoregulatory physiology and strategies aimed at controlling physiologic responses to hypothermia is presented.
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Affiliation(s)
- M Asim Mahmood
- University of South Alabama Stroke Center, Suite 10-I, 2451 Fillingim Street, Mobile, AL 36617, USA
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Kimberger O, Ali SZ, Markstaller M, Zmoos S, Lauber R, Hunkeler C, Kurz A. Meperidine and skin surface warming additively reduce the shivering threshold: a volunteer study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 11:R29. [PMID: 17316456 PMCID: PMC2151895 DOI: 10.1186/cc5709] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Revised: 02/12/2007] [Accepted: 02/23/2007] [Indexed: 11/23/2022]
Abstract
Introduction Mild therapeutic hypothermia has been shown to improve outcome for patients after cardiac arrest and may be beneficial for ischaemic stroke and myocardial ischaemia patients. However, in the awake patient, even a small decrease of core temperature provokes vigorous autonomic reactions–vasoconstriction and shivering–which both inhibit efficient core cooling. Meperidine and skin warming each linearly lower vasoconstriction and shivering thresholds. We tested whether a combination of skin warming and a medium dose of meperidine additively would reduce the shivering threshold to below 34°C without producing significant sedation or respiratory depression. Methods Eight healthy volunteers participated on four study days: (1) control, (2) skin warming (with forced air and warming mattress), (3) meperidine (target plasma level: 0.9 μg/ml), and (4) skin warming plus meperidine (target plasma level: 0.9 μg/ml). Volunteers were cooled with 4°C cold Ringer lactate infused over a central venous catheter (rate ≈ 2.4°C/hour core temperature drop). Shivering threshold was identified by an increase of oxygen consumption (+20% of baseline). Sedation was assessed with the Observer's Assessment of Alertness/Sedation scale. Results Control shivering threshold was 35.5°C ± 0.2°C. Skin warming reduced the shivering threshold to 34.9°C ± 0.5°C (p = 0.01). Meperidine reduced the shivering threshold to 34.2°C ± 0.3°C (p < 0.01). The combination of meperidine and skin warming reduced the shivering threshold to 33.8°C ± 0.2°C (p < 0.01). There were no synergistic or antagonistic effects of meperidine and skin warming (p = 0.59). Only very mild sedation occurred on meperidine days. Conclusion A combination of meperidine and skin surface warming reduced the shivering threshold to 33.8°C ± 0.2°C via an additive interaction and produced only very mild sedation and no respiratory toxicity.
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Affiliation(s)
- Oliver Kimberger
- Department of Anaesthesiology, University of Bern, CH-3010 Bern, Switzerland
| | - Syed Z Ali
- Department of Anaesthesiology, University of Bern, CH-3010 Bern, Switzerland
| | - Monica Markstaller
- Department of Anaesthesiology, University of Bern, CH-3010 Bern, Switzerland
| | - Sandra Zmoos
- Department of Anaesthesiology, University of Bern, CH-3010 Bern, Switzerland
| | - Rolf Lauber
- Department of Anaesthesiology, University of Bern, CH-3010 Bern, Switzerland
| | - Corinne Hunkeler
- Department of Anaesthesiology, University of Bern, CH-3010 Bern, Switzerland
| | - Andrea Kurz
- Department of Anaesthesiology, University of Bern, CH-3010 Bern, Switzerland
- Outcomes Research Institute, University of Louisville, 2301 S 3RD St, Louisville, KY 40292-2001, USA
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Abstract
Temperature management in acute neurologic disorders has received considerable attention in the last 2 decades. Numerous trials of hypothermia have been performed in patients with head injury, stroke, and cardiac arrest. This article reviews the physiology of thermoregulation and mechanisms responsible for hyperpyrexia. Detrimental effects of fever and benefits of normalizing elevated temperature in experimental models are discussed. This article presents a detailed analysis of trails of induced hypothermia in patients with acute neurologic insults and describes methods of fever control.
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Affiliation(s)
- Yekaterina K Axelrod
- Department of Neurology, Washington University School of Medicine, St Louis, MO 63110-1093, USA
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Komatsu R, Orhan-Sungur M, In J, Podranski T, Bouillon T, Lauber R, Rohrbach S, Sessler M.D. DI. Ondansetron does not reduce the shivering threshold in healthy volunteers. Br J Anaesth 2006; 96:732-7. [PMID: 16675509 PMCID: PMC1502385 DOI: 10.1093/bja/ael101] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Ondansetron, a serotonin-3 receptor antagonist, reduces postoperative shivering. Drugs that reduce shivering usually impair central thermoregulatory control, and may thus be useful for preventing shivering during induction of therapeutic hypothermia. We determined, therefore, whether ondansetron reduces the major autonomic thermoregulatory response thresholds (triggering core temperatures) in humans. METHODS Control (placebo) and ondansetron infusions at the target plasma concentration of 250 ng ml(-1) were studied in healthy volunteers on two different days. Each day, skin and core temperatures were increased to provoke sweating; then reduced to elicit peripheral vasoconstriction and shivering. We determined the core-temperature sweating, vasoconstriction and shivering thresholds after compensating for changes in mean-skin temperature. Data were analysed using t-tests and presented as means (sds); P<0.05 was taken as significant. RESULTS Ondensetron plasma concentrations were 278 (57), 234 (55) and 243 (58) ng ml(-1) at the sweating, vasoconstriction and shivering thresholds, respectively; these corresponded to approximately 50 mg of ondansetron which is approximately 10 times the dose used for postoperative nausea and vomiting. Ondansetron did not change the sweating (control 37.4 (0.4) degrees C, ondansetron 37.6 (0.3) degrees C, P=0.16), vasoconstriction (37.0 (0.5) degrees C vs 37.1 (0.3) degrees C; P=0.70), or shivering threshold (36.3 (0.5) degrees C vs 36.3 (0.6) degrees C; P=0.76). No sedation was observed on either study day. CONCLUSIONS /b>. Ondansetron appears to have little potential for facilitating induction of therapeutic hypothermia.
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Affiliation(s)
- Ryu Komatsu
- Research Fellow, Outcomes Research Institute, University of Louisville
| | | | - Jankhyeok In
- Research Fellow, Outcomes Research Institute, University of Louisville
| | - Tobias Podranski
- Attending Anaesthesiologist, Department of Anaesthesiology, University of Bern
| | - Thomas Bouillon
- Attending Anaesthesiologist, Department of Anaesthesiology, University of Bern
| | - Rolf Lauber
- Director, Pharmacokinetic Laboratory, Department of Anaesthesiology, University of Bern
| | - Sibylle Rohrbach
- Laboratory Technician, Department of Anaesthesiology, University of Bern
| | - Daniel I. Sessler M.D.
- Chair, Department of Outcomes Research, The Cleveland Clinic; L&S Weakley Professor and Director, Outcomes Research Institute, University of Louisville
- Corresponding author: Daniel I. Sessler, M.D., Chair, Department of Outcomes Research - E30, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195. Phone: +1 216 870 2620; Fax: +1 502 852 2610; E-mail: . On the world wide web: www.or.org
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Abstract
Experimental evidence and clinical experience suggest that mild hypothermia protects numerous tissues from damage during ischemic insult. However, the extent to which hypothermia becomes a valued therapeutic option will depend on the clinician's ability to rapidly reduce core body temperature and safely maintain hypothermia. To date, general anesthesia is the best way to block autonomic defenses during induction of mild-to-moderate hypothermia; unfortunately, general anesthesia is not an option in most patients likely to benefit from therapeutic hypothermia. Induction of hypothermia in awake humans is complicated by both the technical difficulties related to thermal manipulation and the remarkable efficacy of thermoregulatory defenses, especially vasoconstriction and shivering. The most effective thermal manipulation devices are generally invasive and, therefore, more prone to complications than surface methods. In an effort to inhibit thermoregulation in awake humans, several agents have been tested either alone or in combination with each other. For example, the combination of meperidine and buspirone has already been applied to facilitate induction of hypothermia in human trials. However, pharmacological induction of thermoregulatory tolerance to cold without excessive sedation, respiratory depression, or other serious toxicity remains a major focus of current therapeutic hypothermia research.
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Affiliation(s)
- Anthony G Doufas
- Outcomes Research Institute, Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA.
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Wadhwa A, Sengupta P, Durrani J, Akça O, Lenhardt R, Sessler DI, Doufas AG. Magnesium sulphate only slightly reduces the shivering threshold in humans. Br J Anaesth 2005; 94:756-62. [PMID: 15749735 PMCID: PMC1361806 DOI: 10.1093/bja/aei105] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hypothermia may be an effective treatment for stroke or acute myocardial infarction; however, it provokes vigorous shivering, which causes potentially dangerous haemodynamic responses and prevents further hypothermia. Magnesium is an attractive anti-shivering agent because it is used for treatment of postoperative shivering and provides protection against ischaemic injury in animal models. We tested the hypothesis that magnesium reduces the threshold (triggering core temperature) and gain of shivering without substantial sedation or muscle weakness. METHODS We studied nine healthy male volunteers (18-40 yr) on two randomly assigned treatment days: (1) control and (2) magnesium (80 mg kg(-1) followed by infusion at 2 g h(-1)). Lactated Ringer's solution (4 degrees C) was infused via a central venous catheter over a period of approximately 2 h to decrease tympanic membrane temperature by approximately 1.5 degrees C h(-1). A significant and persistent increase in oxygen consumption identified the threshold. The gain of shivering was determined by the slope of oxygen consumption vs core temperature regression. Sedation was evaluated using a verbal rating score (VRS) from 0 to 10 and bispectral index (BIS) of the EEG. Peripheral muscle strength was evaluated using dynamometry and spirometry. Data were analysed using repeated measures anova; P<0.05 was statistically significant. RESULTS Magnesium reduced the shivering threshold (36.3 [SD 0.4] degrees C vs 36.6 [0.3] degrees C, P = 0.040). It did not affect the gain of shivering (control, 437 [289] ml min(-1) degrees C(-1); magnesium, 573 [370] ml min(-1) degrees C(-1); P=0.344). The magnesium bolus did not produce significant sedation or appreciably reduce muscle strength. CONCLUSIONS Magnesium significantly reduced the shivering threshold. However, in view of the modest absolute reduction, this finding is considered to be clinically unimportant for induction of therapeutic hypothermia.
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Affiliation(s)
- Anupama Wadhwa
- Assistant Professor, OUTCOMES RESEARCH™ Institute and Department of Anesthesiology and Perioperative Medicine, University of Louisville
| | - Papiya Sengupta
- Research Fellow, OUTCOMES RESEARCH™ Institute, University of Louisville
| | - Jaleel Durrani
- Resident, Department of Anesthesiology and Perioperative Medicine, University of Louisville
| | - Ozan Akça
- Assistant Director OUTCOMES RESEARCH™ Institute, Assistant Professor Department of Anesthesiology and Perioperative Medicine, Director Neurosciences Intensive Care Unit, University of Louisville
| | - Rainer Lenhardt
- Assistant Director OUTCOMES RESEARCH™ Institute, Assistant Professor Department of Anesthesiology and Perioperative Medicine, Director Neurosciences Intensive Care Unit, University of Louisville
| | - Daniel I. Sessler
- Vice Dean for Research, Associate Vice President for Health Affairs, Director OUTCOMES RESEARCH™ Institute, Lolita & Samuel Weakley Distinguished University Research Chair, Professor of Anesthesiology and Pharmacology, University of Louisville
| | - Anthony G. Doufas
- Assistant Professor and Director of Research, Department of Anesthesiology and Perioperative Medicine and OUTCOMES RESEARCH™ Institute, University of Louisville
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Mayer SA, Kowalski RG, Presciutti M, Ostapkovich ND, McGann E, Fitzsimmons BF, Yavagal DR, Du YE, Naidech AM, Janjua NA, Claassen J, Kreiter KT, Parra A, Commichau C. Clinical trial of a novel surface cooling system for fever control in neurocritical care patients. Crit Care Med 2005; 32:2508-15. [PMID: 15599159 DOI: 10.1097/01.ccm.0000147441.39670.37] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To compare the efficacy of a novel water-circulating surface cooling system with conventional measures for treating fever in neuro-intensive care unit patients. DESIGN Prospective, unblinded, randomized controlled trial. SETTING Neurologic intensive care unit in an urban teaching hospital. PATIENTS Forty-seven patients, the majority of whom were mechanically ventilated and sedated, with fever > or =38.3 degrees C for >2 consecutive hours after receiving 650 mg of acetaminophen. INTERVENTIONS Subjects were randomly assigned to 24 hrs of treatment with a conventional water-circulating cooling blanket placed over the patient (Cincinnati SubZero, Cincinnati OH) or the Arctic Sun Temperature Management System (Medivance, Louisville CO), which employs hydrogel-coated water-circulating energy transfer pads applied directly to the trunk and thighs. MEASUREMENTS AND MAIN RESULTS Diagnoses included subarachnoid hemorrhage (60%), cerebral infarction (23%), intracerebral hemorrhage (11%), and traumatic brain injury (4%). The groups were matched in terms of baseline variables, although mean temperature was slightly higher at baseline in the Arctic Sun group (38.8 vs. 38.3 degrees C, p = .046). Compared with patients treated with the SubZero blanket (n = 24), Arctic Sun-treated patients (n = 23) experienced a 75% reduction in fever burden (median 4.1 vs. 16.1 C degrees -hrs, p = .001). Arctic Sun-treated patients also spent less percent time febrile (T > or =38.3 degrees C, 8% vs. 42%, p < .001), spent more percent time normothermic (T < or =37.2 degrees C, 59% vs. 3%, p < .001), and attained normothermia faster than the SubZero group median (2.4 vs. 8.9 hrs, p = .008). Shivering occurred more frequently in the Arctic Sun group (39% vs. 8%, p = .013). CONCLUSION The Arctic Sun Temperature Management System is superior to conventional cooling-blanket therapy for controlling fever in critically ill neurologic patients.
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Affiliation(s)
- Stephan A Mayer
- Neurological Intensive Care Unit, Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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