Neural circuits of long-term thermoregulatory adaptations to cold temperatures and metabolic demands

The mammalian brain controls heat generation and heat loss mechanisms that regulate body temperature and energy metabolism. Thermoeffectors include brown adipose tissue, cutaneous blood flow and skeletal muscle, and metabolic energy sources include white adipose tissue. Neural and metabolic pathways modulating the activity and functional plasticity of these mechanisms contribute not only to the optimization of function during acute challenges, such as ambient temperature changes, infection and stress, but also to longitudinal adaptations to environmental and internal changes. Exposure of humans to repeated and seasonal cold ambient conditions leads to adaptations in thermoeffectors such as habituation of cutaneous vasoconstriction and shivering. In animals that undergo hibernation and torpor, neurally regulated metabolic and thermoregulatory adaptations enable survival during periods of significant reduction in metabolic rate. In addition, changes in diet can activate accessory neural pathways that alter thermoeffector activity. This knowledge may be harnessed for therapeutic purposes, including treatments for obesity and improved means of therapeutic hypothermia.

Metabolic Manipulation and Therapeutic Hypothermia

Hypothermia has multiple physiological effects, including decreasing metabolic rate and oxygen consumption (VO2). There are few human data about the magnitude of change in VO2 with decreases in core temperature. We aimed to quantify to magnitude of reduction in resting VO2 as we reduced core temperature in lightly sedated healthy individuals. After informed consent and physical screening, we cooled participants by rapidly infusing 20 mL/kg of cold (4°C) saline intravenously and placing surface cooling pads on the torso. We attempted to suppress shivering using a 1 mcg/kg intravenous bolus of dexmedetomidine followed by titrated infusion at 1.0 to 1.5 μg/(kg·h). We measured resting metabolic rate VO2 through indirect calorimetry at baseline (37°C) and at 36°C, 35°C, 34°C, and 33°C. Nine participants had mean age 30 (standard deviation 10) years and 7 (78%) were male. Baseline VO2 was 3.36 mL/(kg·min) (interquartile range 2.98-3.76) mL/(kg·min). VO2 was associated with core temperature and declined with each degree decrease in core temperature, unless shivering occurred. Over the entire range from 37°C to 33°C, median VO2 declined 0.7 mL/(kg·min) (20.8%) in the absence of shivering. The largest average decrease in VO2 per degree Celsius was by 0.46 mL/(kg·min) (13.7%) and occurred between 37°C and 36°C in the absence of shivering. After a participant developed shivering, core body temperature did not decrease further, and VO2 increased. In lightly sedated humans, metabolic rate decreases around 5.2% for each 1°C decrease in core temperature from 37°C to 33°C. Because the largest decrease in metabolic rate occurs between 37°C and 36°C, subclinical shivering or other homeostatic reflexes may be present at lower temperatures.

Non-pharmacological treatments for shivering post neuraxial anaesthesia for caesarean section: a scoping review

BACKGROUND

Shivering occurs more frequently for women having caesarean section under neuraxial anaesthesia compared to other patient groups and causes an increase in pain and interrupts bonding with her newborn.

AIM

This study aimed to report the evidence on non-pharmacological methods to treat shivering, defined as uncontrollable shaking, because of being cold, frightened, or excited, post neuraxial anaesthesia; the use of local anaesthesia inserted around the nerves of the central nervous system such as spinal anaesthesia and epidural in women having a caesarean section.

METHODS

A scoping review was conducted using six electronic health databases that were searched with no restrictions placed on language, date, or study type.

FINDINGS

Of the 1399 studies identified, following screenings only one study was deemed suitable for inclusion. The study, a randomised controlled trial, compared forced air warming blankets (intervention) with the usual care of warmed cotton blankets (control) and its impact on maternal and newborn outcomes. The only statistically significant difference found was the perceived thermal comfort of the mother.

DISCUSSION

Non-pharmacological treatments for shivering are underrepresented in the literature; only one study identified where the impact of active warming was compared to warmed cotton blankets (usual care) for the measures of: oral temperature; degree of shivering; and thermal comfort pain scores. There was a decline in temperature in both groups at odds with some women reporting feeling too warm such that they asked for the active warmer to be turned down.

CONCLUSION

Social engagement strategies are interventions that send a signal of safety to the nervous system leading to a sense of calm and wellbeing and have biological plausibility and warrant evaluation. Recommendations for further research: design a robust study to test the effectiveness of social engagement strategies on shivering for women having caesarean section under neuraxial anaesthesia.

The Effect of Warmed Serum on Shivering and Recovery Period of Patients Under General and Spinal Anesthesia: A Randomized Clinical Trial

PURPOSE

Postoperative hypothermia followed by shivering is a common phenomenon in patients undergoing surgery under anesthesia, and should be prevented and treated in postoperative patient care units. This study was conducted to investigate the effect of warmed serum injection on postoperative shivering and recovery period of patients operated under general and spinal anesthesia.

DESIGN

In this clinical trial, patients to be operated on under general and spinal anesthesia were randomly assigned into two groups of test and control. In the test group, patients received warmed intravenous fluids and blood products. All patients were monitored to record vital signs, incidences of hypothermia and shivering, and recovery period.

METHODS

The collected data were analyzed with repeated measures analysis of variance to detect significant differences between groups and significant changes within groups over time.

FINDINGS

The incidence of nausea, vomiting, and shivering in the intervention and control groups was (4.7%, 42%), (2.8%, 16.8%), and (6.6%, 43%), respectively. Patients in the intervention group had higher body temperature than the control group (<0.001). Also, patients under spinal anesthesia had higher body temperature than patients under general anesthesia (<0.001). Blood pressure reduction was also significantly higher in the control group than in the intervention group. The patients who received warm intravenous serum, and especially those who had received spinal anesthesia spent less time in the recovery room (<0.001).

CONCLUSIONS

The use of warmed intravenous serum increased the patients' core temperature, reduced their postoperative shivering, and shortened their recovery period. Considering the potential risks associated with hypothermia, using such methods for hypothermia prevention can be highly effective in preventing shivering and prolongation of the recovery period and other potential complications. Anesthesia specialists and technicians are therefore encouraged to use this method as a preventive measure.

Droperidol lowers the shivering threshold in rabbits

PURPOSE

Perioperative shivering is common and can occur as a result of hypothermia or changes in the threshold of thermoregulation. Droperidol usage for anesthesia is currently limited to its sedative and antiemetic effects. We investigated the effects of high and low doses of droperidol on the shivering threshold in rabbits.

METHODS

Forty-two male Japanese white rabbits were anesthetized with isoflurane and randomly assigned to the control, high-dose, or low-dose group. Rabbits in the high-dose group received a 5 mg/kg droperidol bolus followed by continuous infusion at 5 mg/kg/h, those in the low-dose group received a 0.5 mg/kg droperidol bolus, and those in the control group received the same volume of saline as the high-dose group. Body temperature was reduced at a rate of 2-3 °C/h, and the shivering threshold was defined as the subject's core temperature (°C) at the onset of shivering.

RESULTS

The shivering thresholds in the control, high-dose, and low-dose groups were 38.1 °C ± 1.1 °C, 36.7 °C ± 1.2 °C, and 36.9 °C ± 1.0 °C, respectively. The shivering thresholds were significantly lower in the high-dose and low-dose groups than in the control group (P < 0.01). The thresholds were comparable between the high-dose and low-dose groups.

CONCLUSIONS

Droperidol in high and low doses effectively reduced the shivering threshold in rabbits. Droperidol has been used in low doses as an antiemetic. Low doses of droperidol can reduce the incidence of shivering perioperatively and during the induction of therapeutic hypothermia.

Nitrous oxide consistently attenuates thermogenic and thermoperceptual responses to repetitive cold stress in humans

Divers are at enhanced risk of hypothermia, due to the independent action of the inspired inert gases on thermoregulation. Thus, narcosis induced by acute (≤2 h) exposure to either hyperbaric nitrogen or normobaric nitrous oxide (N2O) impairs shivering thermogenesis and accelerates body core cooling. Animal-based studies, however, have indicated that repeated and sustained N2O administration may prevent N2O-evoked hypometabolism. We, therefore, examined the effects of prolonged intermittent exposure to 30% N2O on human thermoeffector plasticity in response to moderate cold. Fourteen men participated in two ∼12-h sessions, during which they performed sequentially three 120-min cold-water immersions (CWIs) in 20°C water, separated by 120-min rewarming. During CWIs, subjects were breathing either normal air or a normoxic gas mixture containing 30% N2O. Rectal and skin temperatures, metabolic heat production (via indirect calorimetry), finger and forearm cutaneous vascular conductance (CVC; laser-Doppler fluxmetry/mean arterial pressure), and thermal sensation and comfort were monitored. N2O aggravated the drop in rectal temperature (P = 0.01), especially during the first (by ∼0.3°C) and third (by ∼0.4°C) CWIs. N2O invariably blunted the cold-induced elevation of metabolic heat production by ∼22%-25% (P < 0.001). During the initial ∼30 min of the first and second CWIs, N2O attenuated the cold-induced drop in finger (P ≤ 0.001), but not in forearm CVC. N2O alleviated the sensation of coldness and thermal discomfort throughout (P < 0.001). Thus, the present results demonstrate that, regardless of the cumulative duration of gas exposure, a subanesthetic dose of N2O depresses human thermoregulatory functions and precipitates the development of hypothermia.NEW & NOTEWORTHY Human thermoeffector plasticity was evaluated in response to prolonged iterative exposure to 30% N2O and moderate cold stress. Regardless of the duration of gas exposure, N2O-induced narcosis impaired in a persistent manner shivering thermogenesis and thermoperception.

Acute basilar artery occlusion with recurrent shivering: A case report

RATIONALE

Shivering is an important physiological response of the body that causes muscle tremors to maintain temperature homeostasis. Traumatic brain injuries that affect the hypothalamus cause hypothermia, and physical removal of suprasellar tumors causes thermoregulation imbalance. However, no study has reported shivering due to ischemic stroke.

PATIENT CONCERNS

A 58-year-old male patient was admitted to our emergency department to evaluate severe stenosis of the basilar artery. While waiting for further examination, he exhibited coarse shivering and severe dysarthria.

DIAGNOSIS

Brain computed tomography angiography revealed occlusion of the entire basilar artery, and cerebral hypoperfusion was diagnosed in that area.

INTERVENTIONS

Transfemoral cerebral angiography (TFCA) was immediately performed, followed by thrombectomy of the basilar artery.

OUTCOMES

Neurological deficits, including shivering, were rapidly reversed. The same symptom reoccurred 5 hours later, and TFCA was performed for thrombectomy and stenting, and neurological symptoms immediately reversed. The patient's neurological symptoms did not worsen during hospitalization.

LESSONS

Patients with acute basilar artery occlusion need prompt management because they have a higher mortality rate than those with other intracranial artery occlusions. When a patient exhibits neurological deficits accompanied by abrupt shivering for no specific reason, basilar artery occlusion must be considered.

Beneficial effect of fluid warming in elderly patients with bladder cancer undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy

OBJECTIVES

The enhanced recovery after surgery (ERAS) protocol recommends prevention of intraoperative hypothermia. However, the beneficial effect of maintaining normothermia after radical cystectomy has not been evaluated. This study aimed to investigate the efficacy of fluid warming nursing in elderly patients undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy.

METHODS

A total of 108 patients with bladder cancer scheduled to undergo DaVinci robotic-assisted laparoscopic radical cystectomy were recruited and randomly divided into the control group (n=55), which received a warming blanket (43°C) during the intraoperative period and the warming group (n=53), in which all intraoperative fluids were administered via a fluid warmer (41°C). The surgical data, body temperature, coagulation function indexes, and postoperative complications were compared between the two groups.

RESULTS

Compared to the control group, the warming group had significantly less intraoperative transfusion (p=0.028) and shorter hospitalization days (p<0.05). During the entire intraoperative period (from 1 to 6h), body temperature was significantly higher in the warming group than in the control group. There were significant differences in preoperative fibrinogen level, white blood cell count, total bilirubin level, intraoperative lactose level, postoperative thrombin time (TT), and platelet count between the control and warming groups. Multivariate linear regression analysis demonstrated that TT was the only significant factor, suggesting that the warming group had a lower TT than the control group.

CONCLUSION

Fluid warming nursing can effectively reduce transfusion requirement and hospitalization days, maintain intraoperative normothermia, and promote postoperative coagulation function in elderly patients undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy.

Effect of different carbon dioxide (CO2) insufflation for laparoscopic colorectal surgery in elderly patients: A randomized controlled trial

BACKGROUND

Evidence suggests that dry CO2 insufflation during laparoscopic colorectal surgery results in greater structural injury to the peritoneum and longer hospital stay than the use of warm, humidified CO2. We aimed to test the hypothesis that warm, humidified CO2 insufflation could reduce postoperative pain and improve recovery in laparoscopic colorectal surgery.

METHODS

One hundred fifty elderly patients undergoing laparoscopic colorectal surgery under general anesthesia from May 2017 to October 2018 were randomly divided into 3 groups. The primary outcomes were resting pain, cough pain, and consumption of sufentanil at 2, 4, 6, 12, 24, and 48 hours postoperatively. Quality of visual image, hemodynamic changes, esophageal temperature, mean skin temperature, mean body temperature, recovery time, days to first flatus and solid food intake, shivering, incidence of postoperative ileus, length of hospital stay, surgical site infections, patients and surgeon satisfaction scores, adverse events, prothrombin time, activated partial thromboplastin time, and thrombin time were recorded.

RESULTS

Group CE patients were associated with significantly higher early postoperative cough pain and sufentanil consumption than the other 2 groups (P < .05). Compared with group CE, patients in both groups WH and CF had significantly reduced intraoperative hypothermia, recovery time of PACU, days to first flatus and solid food intake, and length of hospital stay, while the satisfaction scores of both patients and surgeon were significantly higher (P < .05). Prothrombin time, activated partial thromboplastin time, and thrombin time were significantly higher in group CE from 60 minutes after pneumoperitoneum to the end of pneumoperitoneum than the other 2 groups (P < .05). The number of patients with a shivering grade of 0 was significantly lower and grade of 3 was significantly higher in group CE than in the other 2 groups (P < .05).

CONCLUSION

Use of either warm, humidified CO2 insufflations or 20°C, 0% relative humidity CO2 combined with forced-air warmer set to 38°C during insufflations can both reduce intraoperative hypothermia, dysfunction of coagulation, early postoperative cough pain, sufentanil consumption, days to first flatus, solid food intake, and length of hospital stay.

Effectiveness of Magnesium in Preventing Shivering in Surgical Patients: A Systematic Review and Meta-analysis

BACKGROUND

Clinical trials regarding the antishivering effect of perioperative magnesium have produced inconsistent results. We conducted a systematic review and meta-analysis with Trial Sequential Analysis to evaluate the effect of perioperative magnesium on prevention of shivering.

METHODS

We searched PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, and 2 registry sites for randomized clinical trials that compared the administration of magnesium to a placebo or no treatment in patients undergoing surgeries. The primary outcome of this meta-analysis was the incidence of shivering. The incidence of shivering was combined as a risk ratio with 95% CI using a random-effect model. The effect of the route of administration was evaluated in a subgroup analysis, and Trial Sequential Analysis with a risk of type 1 error of 5% and power of 90% was performed. The quality of each included trial was evaluated, and the quality of evidence was assessed using the Grading of Recommendation Assessment, Development, and Evaluation approach. We also assessed adverse events.

RESULTS

Sixty-four trials and 4303 patients (2300 and 2003 patients in magnesium and control groups, respectively) were included. The overall incidence of shivering was 9.9% in the magnesium group and 23.0% in the control group (risk ratio, 0.42; 95% CI, 0.33-0.52). Subgroup analysis revealed that the incidence of shivering was lower with IV (risk ratio, 0.29; 95% CI, 0.29-0.54; Grading of Recommendation Assessment, Development, and Evaluation, moderate), epidural (risk ratio, 0.24; 95% CI, 0.13-0.43; Grading of Recommendation Assessment, Development, and Evaluation, low), and intrathecal administration (risk ratio, 0.64; 95% CI, 0.43-0.96; Grading of Recommendation Assessment, Development, and Evaluation, moderate). Only trials with low risk of bias were included for Trial Sequential Analysis. The Z-cumulative curve for IV magnesium crossed the Trial Sequential Analysis monitoring boundary for benefit even though only 34.9% of the target sample size had been reached. The Z-cumulative curve for epidural or intrathecal administration did not cross the Trial Sequential Analysis monitoring boundary for benefit. No increase in adverse events was reported.

CONCLUSIONS

Perioperative IV administration of magnesium effectively reduced shivering and Trial Sequential Analysis suggested that no more trials are required to confirm that IV magnesium effectively reduces shivering.

Seven days of cold acclimation substantially reduces shivering intensity and increases nonshivering thermogenesis in adult humans

Daily compensable cold exposure in humans reduces shivering by ~20% without changing total heat production, partly by increasing brown adipose tissue thermogenic capacity and activity. Although acclimation and acclimatization studies have long suggested that daily reductions in core temperature are essential to elicit significant metabolic changes in response to repeated cold exposure, this has never directly been demonstrated. The aim of the present study is to determine whether daily cold-water immersion, resulting in a significant fall in core temperature, can further reduce shivering intensity during mild acute cold exposure. Seven men underwent 1 h of daily cold-water immersion (14°C) for seven consecutive days. Immediately before and following the acclimation protocol, participants underwent a mild cold exposure using a novel skin temperature clamping cold exposure protocol to elicit the same thermogenic rate between trials. Metabolic heat production, shivering intensity, muscle recruitment pattern, and thermal sensation were measured throughout these experimental sessions. Uncompensable cold acclimation reduced total shivering intensity by 36% (P = 0.003), without affecting whole body heat production, double what was previously shown from a 4-wk mild acclimation. This implies that nonshivering thermogenesis increased to supplement the reduction in the thermogenic contribution of shivering. As fuel selection did not change following the 7-day cold acclimation, we suggest that the nonshivering mechanism recruited must rely on a similar fuel mixture to produce this heat. The more significant reductions in shivering intensity compared with a longer mild cold acclimation suggest important differential metabolic responses, resulting from an uncompensable compared with compensable cold acclimation. NEW & NOTEWORTHY Several decades of research have been dedicated to reducing the presence of shivering during cold exposure. The present study aims to determine whether as little as seven consecutive days of cold-water immersion is sufficient to reduce shivering and increase nonshivering thermogenesis. We provide evidence that whole body nonshivering thermogenesis can be increased to offset a reduction in shivering activity to maintain endogenous heat production. This demonstrates that short, but intense cold stimulation can elicit rapid metabolic changes in humans, thereby improving our comfort and ability to perform various motor tasks in the cold. Further research is required to determine the nonshivering processes that are upregulated within this short time period.

Effect of forced-air warming system in prevention of postoperative hypothermia in elderly patients: A Prospective controlled trial

BACKGROUND

Postoperative hypothermia in elderly patients is a well-known serious complication as it impairs wound healing, induces coagulopathy, increases the risk of blood loss, enhances oxygen consumption, and precipitates cardiac arrhythmias. We conducted this randomized controlled trial to evaluate the effect of a forced-air warming system on rewarming elderly patients undergoing total knee or hip arthroplasty.

METHODS

We recruited 243 elderly patients undergoing total knee or hip arthroplasty between May and December 2016. They were divided into three groups according to a computer-generated randomization table: group C (n = 78, rewarmed with only a regular blanket), group F1 (n = 82, rewarmed with a forced-air warming system set at 38°C), and group F2 (n = 83, rewarmed with a forced-air warming system set at 42°C). The nasopharyngeal temperature was recorded every 5 min for the first half hour, then every 10 min up to the end of the PACU (postanesthesia care unit) stay. The primary outcome was the rewarming time. The rewarming rate, increase in nasopharyngeal temperature (compared to the start of rewarming), hemodynamics, recovery time, and incidences of adverse effects were recorded.

RESULTS

No significant differences were found among the three groups in terms of the baseline clinical characteristics, use of narcotic drugs, intraoperative temperature, and hemodynamics (P > .05). Compared with the elderly patients in groups C and F1, both the heart rate and mean arterial pressure of those in group F2 were significantly increased 20 min after arrival at the PACU (P < .05). Patients in group F2 had the shortest rewarming time (35.89 ± 6.45 min, P < .001), highest rewarming efficiency (0.028 ± 0.001°C/min, P < .001), and fastest increased nasopharyngeal temperature among the three groups. Moreover, the elderly patients in group F2 had lower incidences of arrhythmia and shivering (P < .05).

CONCLUSIONS

The use of a forced-air warming system set at 42°C was shown to be the most effective way of rewarming elderly patients with postoperative hypothermia.

Central nervous system circuits that control body temperature

Maintenance of mammalian core body temperature within a narrow range is a fundamental homeostatic process to optimize cellular and tissue function, and to improve survival in adverse thermal environments. Body temperature is maintained during a broad range of environmental and physiological challenges by central nervous system circuits that process thermal afferent inputs from the skin and the body core to control the activity of thermoeffectors. These include thermoregulatory behaviors, cutaneous vasomotion (vasoconstriction and, in humans, active vasodilation), thermogenesis (shivering and brown adipose tissue), evaporative heat loss (salivary spreading in rodents, and human sweating). This review provides an overview of the central nervous system circuits for thermoregulatory reflex regulation of thermoeffectors.

Physiological responses to acute cold exposure in young lean men

The aim of this study was to comprehensively describe the physiological responses to an acute bout of mild cold in young lean men (n = 11, age: 23 ± 2 years, body mass index: 23.1 ± 1.2 kg/m2) to better understand the underlying mechanisms of non-shivering thermogenesis and how it is regulated. Resting energy expenditure, substrate metabolism, skin temperature, thermal comfort perception, superficial muscle activity, hemodynamics of the forearm and abdominal regions, and heart rate variability were measured under warm conditions (22.7 ± 0.2°C) and during an individualized cooling protocol (air-conditioning and water cooling vest) in a cold room (19.4 ± 0.1°C). The temperature of the cooling vest started at 16.6°C and decreased ~ 1.4°C every 10 minutes until participants shivered (93.5 ± 26.3 min). All measurements were analysed across 4 periods: warm period, at 31% and at 64% of individual´s cold exposure time until shivering occurred, and at the shivering threshold. Energy expenditure increased from warm period to 31% of cold exposure by 16.7% (P = 0.078) and to the shivering threshold by 31.7% (P = 0.023). Fat oxidation increased by 72.6% from warm period to 31% of cold exposure (P = 0.004), whereas no changes occurred in carbohydrates oxidation. As shivering came closer, the skin temperature and thermal comfort perception decreased (all P<0.05), except in the supraclavicular skin temperature, which did not change (P>0.05). Furthermore, the superficial muscle activation increased at the shivering threshold. It is noteworthy that the largest physiological changes occurred during the first 30 minutes of cold exposure, when the participants felt less discomfort.

Afferent pathways for autonomic and shivering thermoeffectors

Body core temperature of mammals is regulated by the central nervous system, in which the preoptic area (POA) of the hypothalamus plays a pivotal role. The POA receives peripheral and central thermosensory neural information and provides command signals to effector organs to elicit involuntary thermoregulatory responses, including shivering thermogenesis, nonshivering brown adipose tissue thermogenesis, and cutaneous vasoconstriction. Cool-sensory and warm-sensory signals from cutaneous thermoreceptors, monitoring environmental temperature, are separately transmitted through the spinal-parabrachial-POA neural pathways, distinct from the spinothalamocortical pathway for perception of skin temperature. These cutaneous thermosensory inputs to the POA likely impinge on warm-sensitive POA neurons, which monitor body core (brain) temperature, to alter thermoregulatory command outflows from the POA. The cutaneous thermosensory afferents elicit rapid thermoregulatory responses to environmental thermal challenges before they impact body core temperature. Peripheral humoral signals also act on neurons in the POA to transmit afferent information of systemic infection and energy storage to induce fever and to regulate energy balance, respectively. This chapter describes the thermoregulatory afferent mechanisms that convey cutaneous thermosensory signals to the POA and that integrate the neural and humoral afferent inputs to the POA to provide descending command signals to thermoregulatory effectors.

Efferent neural pathways for the control of brown adipose tissue thermogenesis and shivering

The fundamental central neural circuits for thermoregulation orchestrate behavioral and autonomic repertoires that maintain body core temperature during thermal challenges that arise from either the ambient or the internal environment. This review summarizes our understanding of the neural pathways within the fundamental thermoregulatory reflex circuitry that comprise the efferent (i.e., beyond thermosensory) control of brown adipose tissue (BAT) and shivering thermogenesis: the motor neuron systems consisting of the BAT sympathetic preganglionic neurons and BAT sympathetic ganglion cells, and the alpha- and gamma-motoneurons; the premotor neurons in the region of the rostral raphe pallidus, and the thermogenesis-promoting neurons in the dorsomedial hypothalamus/dorsal hypothalamic area. Also included are inputs to, and neurochemical modulators of, these efferent neuronal populations that could influence their activity during thermoregulatory responses. Signals of metabolic status can be particularly significant for the energy-hungry thermoeffectors for heat production.

A Simple Algorithm for Predicting Bacteremia Using Food Consumption and Shaking Chills: A Prospective Observational Study

BACKGROUND

Predicting the presence of true bacteremia based on clinical examination is unreliable.

OBJECTIVE

We aimed to construct a simple algorithm for predicting true bacteremia by using food consumption and shaking chills.

DESIGN

A prospective multicenter observational study.

SETTING

Three hospital centers in a large Japanese city.

PARTICIPANTS

In total, 1,943 hospitalized patients aged 14 to 96 years who underwent blood culture acquisitions between April 2013 and August 2014 were enrolled. Patients with anorexia-inducing conditions were excluded.

INTERVENTIONS

We assessed the patients' oral food intake based on the meal immediately prior to the blood culture with definition as "normal food consumption" when >80% of a meal was consumed and "poor food consumption" when <80% was consumed. We also concurrently evaluated for a history of shaking chills.

MEASUREMENTS

We calculated the statistical characteristics of food consumption and shaking chills for the presence of true bacteremia, and subsequently built the algorithm by using recursive partitioning analysis.

RESULTS

Among 1,943 patients, 223 cases were true bacteremia. Among patients with normal food consumption, without shaking chills, the incidence of true bacteremia was 2.4% (13/552). Among patients with poor food consumption and shaking chills, the incidence of true bacteremia was 47.7% (51/107). The presence of poor food consumption had a sensitivity of 93.7% (95% confidence interval [CI], 89.4%-97.9%) for true bacteremia, and the absence of poor food consumption (ie, normal food consumption) had a negative likelihood ratio (LR) of 0.18 (95% CI, 0.17-0.19) for excluding true bacteremia, respectively. Conversely, the presence of the shaking chills had a specificity of 95.1% (95% CI, 90.7%-99.4%) and a positive LR of 4.78 (95% CI, 4.56-5.00) for true bacteremia.

CONCLUSION

A 2-item screening checklist for food consumption and shaking chills had excellent statistical properties as a brief screening instrument for predicting true bacteremia.

Recent advances in thermoregulation

Thermoregulation is the maintenance of a relatively constant core body temperature. Humans normally maintain a body temperature at 37°C, and maintenance of this relatively high temperature is critical to human survival. This concept is so important that control of thermoregulation is often the principal example cited when teaching physiological homeostasis. A basic understanding of the processes underpinning temperature regulation is necessary for all undergraduate students studying biology and biology-related disciplines, and a thorough understanding is necessary for those students in clinical training. Our aim in this review is to broadly present the thermoregulatory process taking into account current advances in this area. First, we summarize the basic concepts of thermoregulation and subsequently assess the physiological responses to heat and cold stress, including vasodilation and vasoconstriction, sweating, nonshivering thermogenesis, piloerection, shivering, and altered behavior. Current research is presented concerning the body's detection of thermal challenge, peripheral and central thermoregulatory control mechanisms, including brown adipose tissue in adult humans and temperature transduction by the relatively recently discovered transient receptor potential channels. Finally, we present an updated understanding of the neuroanatomic circuitry supporting thermoregulation.

Two strategies for response to 14 °C cold-water immersion: is there a difference in the response of motor, cognitive, immune and stress markers?

Here, we address the question of why some people have a greater chance of surviving and/or better resistance to cold-related-injuries in prolonged exposure to acute cold environments than do others, despite similar physical characteristics. The main aim of this study was to compare physiological and psychological reactions between people who exhibited fast cooling (FC; n = 20) or slow cooling (SC; n = 20) responses to cold water immersion. Individuals in whom the T(re) decreased to a set point of 35.5 °C before the end of the 170-min cooling time were indicated as the FC group; individuals in whom the T(re) did not decrease to the set point of 35.5 °C before the end of the 170-min cooling time were classified as the SC group. Cold stress was induced using intermittent immersion in bath water at 14 °C. Motor (spinal and supraspinal reflexes, voluntary and electrically induced skeletal muscle contraction force) and cognitive (executive function, short term memory, short term spatial recognition) performance, immune variables (neutrophils, leucocytes, lymphocytes, monocytes, IL-6, TNF-α), markers of hypothalamic-pituitary-adrenal axis activity (cortisol, corticosterone) and autonomic nervous system activity (epinephrine, norepinephrine) were monitored. The data obtained in this study suggest that the response of the FC group to cooling vs the SC group response was more likely an insulative-hypothermic response and that the SC vs the FC group displayed a metabolic-insulative response. The observations that an exposure time to 14 °C cold water--which was nearly twice as short (96-min vs 170-min) with a greater rectal temperature decrease (35.5 °C vs 36.2 °C) in the FC group compared with the SC group--induces similar responses of motor, cognitive, and blood stress markers were novel. The most important finding is that subjects with a lower cold-strain-index (SC group) showed stimulation of some markers of innate immunity and suppression of markers of specific immunity.

[Shivering associated with general anesthesia using remifentanil]

General anesthesia using remifentanil is accompanied with post-operative shivering at a high incidence. Post-operative shivering can be divided into thermoregulatory and non-thermoregulatory. Hypothermia causes thermoregulatory shivering. The interthreshold range is defined as the difference between the sweating threshold and the vasoconstriction threshold. Generally, the interthreshold range is shifted to higher temperatures immediately after surgery under general anesthesia. Thus, thermoregulatory shivering can be exaggerated in patients without hypothermia. The application of patient warming devices and the administration of non-steroidal anti-inflammatory drugs are considered as effective treatments for the prevention of thermoregulatory shivering. Remifentanil is an ultra-short acting agent. Pharmacological effects of remifentanil quickly disappear just after the discontinuing of remifentanil infusion, leading to a kind of opioid withdrawal syndrome resulting in non-thermoregulatory shivering. In addition, postoperative pain shifts the shivering threshold to higher temperatures, resulting in non-thermoregulatory shivering. Thus, opioid transition using fentanyl and/or morphine during anesthetic management is essential for the prevention of non-thermoregulatory shivering. It is also reported that magnesium, ketamine and pethidine have preventive effects on non-thermoregulatory shivering. The mechanism underlying post-operative shivering associated with general anesthesia using remifentanil is very complicated; therefore, we speculate that multimodal approach is required for its prevention.

Isothermal dialysis to control intradialytic hypotension and patient comfort: a pilot study

Isothermal hemodialysis to improve intradialytic tolerance in hypotension-prone patients has been effective in outpatient settings. The purpose of this pilot study was to examine thermal control in an acute care setting and describe comfort issues associated with thermal control Although complaints of cold or shivering occurred more frequently with the isothermal hemodialysis group, cold discomfort was managed by nursing interventions and was not a cause of significant discomfort. No statistically significant difference was observed in blood pressure or patient's comfort level between standard and isothermal dialysis. However, isothermal hemodialysis may be an appropriate hemodialysis option for control of intradialytic hypotension in the acute care setting. Further research is recommended.

Brown adipose tissue and the regulation of nonshivering thermogenesis

PURPOSE OF REVIEW

The recent rediscovery of functional cold activated brown adipose tissue (BAT) in adult humans fuelled an uprise in studies on this tissue. This review focuses on the contribution of human BAT to nonshivering thermogenesis and on factors other than cold that activate BAT.

RECENT FINDINGS

Earlier studies revealed BAT activity using a glucose tracer for positron emission tomography/computed tomography (PET/CT) scanning. Several recent studies, using a mix of tracers and PET/CT dynamic scanning showed that human brown fat is metabolically active and related to the perfusion of the tissue. The actual contribution of BAT to nonshivering thermogenesis still needs to be explored.The last few years, several new factors that activate human BAT have been described. These studies also highlight the plasticity of brown and white adipose tissue. Some of these factors may have pharmacological significance.

SUMMARY

New PET/CT studies provide information on oxidative human BAT metabolism in vivo. This new information in combination with the study on factors activating BAT are promising with respect to management of obesity and related disorders.

Shivering management during therapeutic temperature modulation: nurses' perspective

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.

Acute cold exposure and cognitive function: evidence for sustained impairment

Several industries experience periods of cold exposure and rewarming throughout the workday but mental performance under these conditions is unknown. A better understanding of cognition during the rewarming phase after cold exposure may help reduce accidents and improve performance. Ten young men (wearing ~0.1 clo) underwent three consecutive mornings trials where they were exposed to cold air (10°C) and then subsequently rewarmed (25°C air). A computerised test battery was administered during each stage of the protocol to determine working memory, choice reaction time, executive function and maze navigation. Rectal and skin temperature, oxygen consumption and thermal sensation were also measured throughout and showed a typical response. Relative to baseline performance, working memory, choice reaction time and executive function declined during exposure to 10°C, and these impairments persisted 60 min into the recovery period (i.e. once physiological parameters had returned to baseline). Further work is needed to develop countermeasures to this predicament.

PRACTITIONER SUMMARY

This study showed that working memory, choice reaction time and executive function declined during exposure to 10°C air, and these impairments persisted 60 min into the rewarming period (i.e. once measurable physiological parameters had returned to normal). Individuals may be at risk for injury after removal from a cold environment.

β₁-Adrenergic receptors increase UCP1 in human MADS brown adipocytes and rescue cold-acclimated β₃-adrenergic receptor-knockout mice via nonshivering thermogenesis

With the finding that brown adipose tissue is present and negatively correlated to obesity in adult man, finding the mechanism(s) of how to activate brown adipose tissue in humans could be important in combating obesity, type 2 diabetes, and their complications. In mice, the main regulator of nonshivering thermogenesis in brown adipose tissue is norepinephrine acting predominantly via β(3)-adrenergic receptors. However, vast majorities of β(3)-adrenergic agonists have so far not been able to stimulate human β(3)-adrenergic receptors or brown adipose tissue activity, and it was postulated that human brown adipose tissue could be regulated instead by β(1)-adrenergic receptors. Therefore, we have investigated the signaling pathways, specifically pathways to nonshivering thermogenesis, in mice lacking β(3)-adrenergic receptors. Wild-type and β(3)-knockout mice were either exposed to acute cold (up to 12 h) or acclimated for 7 wk to cold, and parameters related to metabolism and brown adipose tissue function were investigated. β(3)-knockout mice were able to survive both acute and prolonged cold exposure due to activation of β(1)-adrenergic receptors. Thus, in the absence of β(3)-adrenergic receptors, β(1)-adrenergic receptors are effectively able to signal via cAMP to elicit cAMP-mediated responses and to recruit and activate brown adipose tissue. In addition, we found that in human multipotent adipose-derived stem cells differentiated into functional brown adipocytes, activation of either β(1)-adrenergic receptors or β(3)-adrenergic receptors was able to increase UCP1 mRNA and protein levels. Thus, in humans, β(1)-adrenergic receptors could play an important role in regulating nonshivering thermogenesis.

Automated discrimination of brain pathological state attending to complex structural brain network properties: the shiverer mutant mouse case

Neuroimaging classification procedures between normal and pathological subjects are sparse and highly dependent of an expert's clinical criterion. Here, we aimed to investigate whether possible brain structural network differences in the shiverer mouse mutant, a relevant animal model of myelin related diseases, can reflect intrinsic individual brain properties that allow the automatic discrimination between the shiverer and normal subjects. Common structural networks properties between shiverer (C3Fe.SWV Mbp(shi)/Mbp(shi), n = 6) and background control (C3HeB.FeJ, n = 6) mice are estimated and compared by means of three diffusion weighted MRI (DW-MRI) fiber tractography algorithms and a graph framework. Firstly, we found that brain networks of control group are significantly more clustered, modularized, efficient and optimized than those of the shiverer group, which presented significantly increased characteristic path length. These results are in line with previous structural/functional complex brain networks analysis that have revealed topologic differences and brain network randomization associated to specific states of human brain pathology. In addition, by means of network measures spatial representations and discrimination analysis, we show that it is possible to classify with high accuracy to which group each subject belongs, providing also a probability value of being a normal or shiverer subject as an individual anatomical classifier. The obtained correct predictions (e.g., around 91.6-100%) and clear spatial subdivisions between control and shiverer mice, suggest that there might exist specific network subspaces corresponding to specific brain disorders, supporting also the point of view that complex brain network analyses constitutes promising tools in the future creation of interpretable imaging biomarkers.

Effect of ascorbic acid on fatigue of skeletal muscle fibres in long-term cold exposed Sprague Dawley rats

BACKGROUND

On exposure to prolonged cold temperature, the body responds for effective heat production both by shivering and non-shivering thermogenesis. Cold exposure increases the production of reactive oxygen species which influence the sarcoplasmic reticulum Ca++ release from the skeletal muscles and affect their contractile properties. The role of ascorbic acid supplementation on force of contraction during fatigue of cold exposed skeletal muscles was evaluated in this study.

METHOD

Ninety healthy, male Sprague Dawley rats were randomly divided into three groups of control (I), cold exposed (II), and cold exposed with ascorbic acid 500 mg/L supplementation mixed in drinking water (III). Group II and III were given cold exposure by keeping their cages in ice-filled tubs for 1 hr/day for one month. After one month, the extensor digitorum longus muscle was dissected out and force of contraction during fatigue in the skeletal muscle fibres was analysed on a computerised data acquisition system.

RESULTS

The cold exposed group showed a significant delay in the force of contraction during fatigue of skeletal muscle fibres compared to control group. Group III showed easy fatigability and a better force of contraction than the cold exposed group.

CONCLUSIONS

Ascorbic acid increases the force of contraction and decreases resistance to fatigue in the muscles exposed to chronic cold.

Shivering heat production and body fat protect the core from cooling during body immersion, but not during head submersion: a structural equation model

Previous studies showed that core cooling rates are similar when only the head or only the body is cooled. Structural equation modeling was used on data from two cold water studies involving body-only, or whole body (including head) cooling. Exposure of both the body and head increased core cooling, while only body cooling elicited shivering. Body fat attenuates shivering and core cooling. It is postulated that this protection occurs mainly during body cooling where fat acts as insulation against cold. This explains why head cooling increases surface heat loss with only 11% while increasing core cooling by 39%.

Metabolic requirements of shivering humans

This review examines the heat production component of thermoregulation in adult humans. It describes the energy requirements of shivering muscles as they attempt to provide sufficient heat to counterbalance increases in heat loss in cold environments. Emphasis is placed on types of metabolic substrates used under various shivering conditions as well as on the effects energy deficit and food consumption. During shivering, muscle recruitment intensity and pattern of fiber recruitment are highly variable between muscles and individuals. In addition, a number of studies have indicated that shivering can be sustained with different fuels for several hours under variable conditions of cold stress and CHO availability. However, little is still known on the effects of prolonged fasting and energy deficit in the cold on energy metabolism. Even though it is clear that food consumption increases the odds for survival, the metabolic fate of ingested substrates remains highly uncertain. Combining fundamental principles surrounding metabolic fuel selection with applied knowledge of human performance in the cold may allow important breakthroughs in this field of research.

Behavioral temperature regulation in humans during mild narcosis induced by inhalation of 30% nitrous oxide

In this study, we investigated the influence of mild narcosis on temperature perception, thermal comfort, and behavioral temperature regulation in humans. Twelve subjects (six males and six females) participated in two trials, during which they wore a water-perfused suit (WPS). The temperature of the WPS (TWPS) fluctuated sinusoidally from 27 degrees to 42 degrees C, at a heating and cooling rate of 1.2 degrees C x min(-1). In the first trial, the subjects had no control over TWPS: They determined their thermal comfort zone (TCZ) by providing a subjective response whenever they perceived the temperature changing from a comfortable to an uncomfortable level and vice versa; in addition, they provided subjective ratings of temperature perception and thermal comfort on a 7-point and 4-point scale, respectively, at each 3 degrees C change in TWPS. In the second trial, subjects could change the direction of TWPS whenever it became uncomfortable by depressing a button on a manual control. The protocols were conducted with subjects breathing either room air (AIR), or a normoxic breathing mixture containing 30% N2O. Subjects perceived increasing TWPS as equally warm and the decreasing TWPS as equally cold with AIR or N2O. However, equal changes in TWPS were perceived as significantly less discomforting (P<0.05) during N2O, and the magnitude of the TCZ significantly (P<0.01) increased. Thus, narcosis did not alter thermal sensation, but it significantly changed the perception of comfort. These changes were not reflected in the behavioral response. Subjects produced similar TWPS damped-oscillation patterns in the AIR and N2O trials. We conclude that the narcosis-induced alteration in the perception of thermal comfort does not change the preferred temperature, or the ability to behaviorally maintain thermal comfort.

The MT pool size ratio and the DTI radial diffusivity may reflect the myelination in shiverer and control mice

A quantitative magnetization transfer (qMT) technique was employed to quantify the ratio of the sizes of the bound and free water proton pools in ex vivo mouse brains. The goal was to determine the pool size ratio sensitivity to myelin. Fixed brains from both shiverer mice and control littermates were imaged. The pool size ratio in the corpus callosum of shiverer mice was substantially lower than that in the control mice, while there was no distinguishable difference in the pool size ratio in the gray matter. These results correlate with diffusion tensor imaging (DTI) derived radial diffusivity which previously was shown to reflect myelin integrity in this animal model. Histological study reveals the presence of myelin in control mice white matter and the absence of myelin in shiverer mice white matter, supporting the qMT and DTI results. Our findings support the view that qMT may be used for estimating myelin integrity.

Perioperative complications of hypothermia

Perioperative hypothermia is a common and serious complication of anesthesia and surgery and is associated with many adverse perioperative outcomes. It prolongs the duration of action of inhaled and intravenous anesthetics as well as the duration of action of neuromuscular drugs. Mild core hypothermia increases thermal discomfort, and is associated with delayed post anaesthetic recovery. Mild hypothermia significantly increases perioperative blood loss and augments allogeneic transfusion requirement. Only 1.9 degrees C core hypothermia triples the incidence of surgical wound infection following colon resection and increases the duration of hospitalization by 20%. Hypothermia adversely affects antibody- and cell-mediated immune defences, as well as the oxygen availability in the peripheral wound tissues. Furthermore mild hypothermia triples the incidence of postoperative adverse myocardial events. Thus, even mild hypothermia contributes significantly to patient care costs and needs to be avoided.

Ice-cold saline for the induction of mild hypothermia in patients with acute ischemic stroke: a pilot study

BACKGROUND AND PURPOSE

Neuroprotective effects of induced hypothermia depend on its time point of initiation after acute brain injury. Preliminary studies in cardiac arrest patients indicate that rapid infusion of ice cold saline (ICS) is safe and effective for induction of hypothermia. We investigated its use in patients with acute ischemic stroke (AIS).

METHODS

Patients (n=10) with AIS were included within 3 hours after symptom onset. After cranial CT, they were treated-if indicated-with rt-PA. ICS of 4 degrees C (25 mL/kg body weight) was administered via peripheral intravenous lines. Patients received buspirone/pethidine to prevent and treat shivering. After infusion of the target volume of ICS, no further efforts were made to maintain hypothermia by other methods.

RESULTS

Ten patients with a median National Institutes of Health Stroke Scale (NIHSS) score of 5.5 (range 4 to 12) on admission were included into the study. Nine patients were treated with thrombolysis within a time window of 104+/-25 minutes. A mean amount of 2163+/-256 mL ICS was infused 17+/-11 minutes after rt-PA infusion had started. Tympanic temperature dropped significantly by a maximum of 1.6+/-0.3 degrees C (P<0.005) at 52+/-16 minutes after ICS was started. The procedure was well tolerated. The NIHSS score improved significantly to a median of 1 (range 1 to 15) at discharge compared to admission (P<0.02).

CONCLUSIONS

This pilot study suggests that rapid ICS infusions in combination with pethidine and buspirone lower the body temperature significantly without major side effects.

Shaking rigors in parturients

OBJECTIVE

To describe the frequency, duration and timing of shaking rigors during parturition and their associations with several clinical variables.

STUDY DESIGN

A total of 467 term, singleton paturients at a single hospital over a 13-month recruitment period were observed by their labor nurses for shaking rigors. Thirteen clinical variables, including length of labor, were also recorded. Multiple regression procedures were used to evaluate associations with presence or absence, number and total duration of rigors. The relationship in time between shaking rigors and sentinel events in labor was also examined. With this sample size, we had > 80% power to detect differences as small as 0.26 effect size units for continuous measures, or ORs of 1.75 or greater for categorical measures, when comparing patients with and without rigors.

RESULTS

In total, 57% of parturients experienced at least 1 rigor. Epidural usage was related to risk, duration and number of rigors. Increased maximum temperature was associated with an increased chance of rigors. Epidural, birth and maternal fever were antecedent events.

CONCLUSION

Over half of parturients experienced shaking rigors. Epidural administration and fever were associated with an increased probability of rigors and an increased number of episodes.

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.

Fueling shivering thermogenesis during passive hypothermic recovery

In humans, the relative importance of oxidative fuels for sustaining shivering during passive hypothermic recovery or rewarming is still unclear. The main goals of this study were 1) to quantify the respective contributions of lipids and carbohydrates (CHO) during passive rewarming and 2) to determine the effects of precooling exercise on the pattern of fuel utilization. With indirect calorimetry methodologies, changes in fuel metabolism were quantified in nonacclimatized adult men shivering to rewarm from moderate hypothermia (core temperature ∼34.5°C) not following (Con) or following a precooling exercise at 75% V̇o2max for 15 min (Pre-CE). As hypothermic individuals shiver to normothermia, results showed that CHO dominate at all shivering intensities above 50% Shivpeak, while lipids were preferred at lower intensities. This change in the relative importance of CHO and lipids to total heat production was dictated entirely by modulating CHO oxidation rate, which decreased by as much as 10-fold from the beginning to the end of rewarming (from 1,611 ± 396 to 141 ± 361 mg/min for Con and 1,555 ± 230 to 207 ± 261 mg/min for Pre-CE). In contrast, lipid oxidation rate remained constant and low (relatively to maximal rates at exercise) throughout rewarming, averaging 183 ± 141 for Con and 207 ± 118 mg lipids/min for Pre-CE. In addition, this pattern of fuel selection remained the same between treatments. We concluded that fuel selection is regulated entirely by changes in CHO oxidation rate. Further research should focus on establishing the exact regulatory processes involved in achieving this large upregulation of CHO utilization rate following hypothermia.

Cold-induced alterations of phospholipid fatty acyl composition in brown adipose tissue mitochondria are independent of uncoupling protein-1

The recruitment process induced by acclimation of mammals to cold includes a marked alteration in the acyl composition of the phospholipids of mitochondria from brown adipose tissue: increases in 18:0, 18:2(n-6), and 20:4(n-6) and decreases in 16:0, 16:1, 18:1, and 22:6(n-3). A basic question is whether these alterations are caused by changes in the concentration of uncoupling protein-1 (UCP1) or the thermogenesis it mediates-implying that they are secondary effects-or whether they are an integrated, independent part of the recruitment process. This question was addressed here using wild-type and UCP1-ablated C57BL/6 mice acclimated to 24 degrees C or 4 degrees C. In wild-type mice, the phospholipid fatty acyl composition of mitochondria from brown adipose tissue showed the changes in response to cold that were expected from observations in other species and strains. The changes were specific, as different changes occurred in skeletal muscle mitochondria. In UCP1-ablated mice, cold acclimation induced acyl alterations in brown adipose tissue that were qualitatively identical and quantitatively similar to those in wild-type mice. Therefore, neither the increased content of UCP1 nor mitochondrial uncoupling altered the effect of cold on acyl composition. Cold acclimation in wild-type mice had little effect on phospholipid acyl composition in muscle mitochondria, but cold-acclimation in UCP1-ablated mice caused significant alterations, probably due to sustained shivering. Thus, the alterations in brown adipose tissue phospholipid acyl composition are revealed to be an independent part of the recruitment process, and their functional significance for thermogenesis should be elucidated.

Unilateral shivering: a result of lateral medullary infarction

Shivering is mediated via the predominantly uncrossed reticulospinal tract. We report a case of a patient with left lateral medullary tract infarct involving the reticulospinal tract who displayed ipsilateral absence of shivering during a febrile episode. The physiology and anatomy of shivering and the reticulospinal tract is reviewed.

Progress in shivering control

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.

Meperidine and skin surface warming additively reduce the shivering threshold: a volunteer study

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.

Lipid mobilization of long-distance migrant birds in vivo: the high lipolytic rate of ruff sandpipers is not stimulated during shivering

For long migrations, birds must rely on high flux capacities at all steps of lipid metabolism, from the mobilization of adipose reserves to fatty acid oxidation in flight muscle mitochondria. Substrate kinetics and indirect calorimetry were used to investigate key parameters of lipid metabolism in a highly aerobic shorebird: the ruff sandpiper Philomachus pugnax. In this study, we have quantified the effects of cold exposure because such measurements are presently impossible during flight. Lipolytic rate was monitored by continuous infusion of 2-[3H]-glycerol and lipid oxidation by respirometry. Plasma lipid concentrations (non-esterified fatty acids, neutral lipids and phospholipids) and their fatty acid composition were also measured to assess whether cold exposure causes selective metabolism of specific lipids. Results show that shivering leads to a 47% increase in metabolic rate (44.4±3.8 ml O2kg–1min–1 to 65.2±8.1 ml O2kg–1 min–1), almost solely by stimulating lipid oxidation (33.3± 3.3 ml O2 kg–1min–1 to 48.2±6.8 ml O2kg–1 min–1) because carbohydrate oxidation remains close to 11.5± 0.5 ml O2 kg–1min–1. Sandpipers support an unusually high lipolytic rate of 55–60 μmol glycerol kg–1 min–1. Its stimulation above thermoneutral rates is unnecessary during shivering when the birds are still able to re-esterify 50% of released fatty acids. No changes in plasma lipid composition were observed, suggesting that cold exposure does not lead to selective metabolism of particular fatty acids. This study provides the first measurements of lipolytic rate in migrant birds and shows that their capacity for lipid mobilization reaches the highest values measured to date in vertebrates. Extending the limits of conventional lipid metabolism has clearly been necessary to achieve long-distance migrations.

Cold-induced heat production preceding shivering

Individual changes in heat production and body temperature were studied in response to cold exposure, prior to shivering. The subjects ten women (seven men) were of normal weight, had a mean age of 23 (SD 3) years and average BMI 22·2 (SD 1·6) Kg/m2. They were lying supine under thermoneutral conditions for 30 min and were subsequently exposed to air of 15°C until shivering occurred. Heat production was measured with a ventilated hood. Body composition was measured with underwater weighing and 2H dilution. Body temperatures were measured with thermistors. Heat production during cold exposure prior to shivering increased and reached a plateau. Skin temperature decreased and did not reach a plateau during the test period. The non-shivering interval (NSI) ranged from 20 to 148 min, was not related to body composition and was not significantly different between women (81 (sd 15) min) and men (84 (sd 34) min). NSI was negatively related to skin temperature (r2 0·44, P=0·004), and skin temperature was related to heat production (r2 0·39, P=0·007) In conclusion, subjects with a relatively large heat production during cold exposure maintained a relatively high skin temperature but showed a short NSI, independent of differences in body composition.