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Thermoregulation involves a long term adaptation system with hormonal processes and an immediate regulation system by extrapyramidal tracts, sympathetic part of autonomic nervous system and cortical integration of body temperature changes. Both system are under control of a hypothalamic center. Prolonged accidental exposure to intense cold and myxoedematous coma are the best known etiologies of hypothermia. However milder and often misdiagnosed hypothermia can occur at home in patients without endocrinologic disease. In these cases, hypothermia is due to dysfunction of immediate thermregulation under neuronal control, especially somatomotor and autonomic system. We report four cases of hypothermia of this kind. Two patients had an inhibition of peripherical mechanisms of protecting against cold (cutaneous vasoconstriction, shivering) and had dampened perception of cold: one was 73, had diabetes mellitus and took different drugs, the other one suffered from systemic lupus with myelopathy. The two other patients probably had a disorder of the thermoregulation hypothalamic center: one had Wernicke's encephalopathy and the other multiple sclerosis. From these cases and a review of the literature, we describe the different etiologies of hypothermia and their pathophysiology.
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PMID:[Hypothermia and the nervous system. Review of the literature apropos of 4 cases]. 876 Jun 89

A total of 325 patients, aged 80 to 92 (mean 82), underwent cardiac operations with cardiopulmonary bypass over a 4-year period (1991-1995). Hypothermia (22 degrees C) and hyperkalemic cardioplegia were used in each. Coronary bypass procedures only (Group I) were performed in 255 patients with 22 early deaths (8.6%), and the average number of grafts was 3.7 per patient. Single or double valve replacement, with coronary bypass (Group II) was performed in 46 patients, with six early deaths (13%). Single or double valve replacement, without coronary bypass (Group III) was performed in 24 patients, with two early deaths (8.3%). Total hospital mortality was 30 deaths in 325 patients (9.2%). Fifty-six procedures (22%) from Group I and four (9%) from Group II were performed as emergencies, and all operations in Group III were elective. Seventy-two patients (27%) from Group I, 18 patients (39%) from Group II, and nine patients (37%) from Group III had major complications including renal failure, cerebrovascular accident, myocardial infarction, postoperative hemorrhage, sepsis, and ventilatory dependency. Mean hospital stay was 10.5 days for Group I, 13.3 days for Group II, and 15.2 days for Group III, with an overall mean of 13 days (range, 6-52) days. Higher mortality was related to a cardiac index <1.8, cardiogenic shock, emergency operation, creatinine >2.0, and morbid obesity. Mean left ventricular ejection fractions were 0.51 for Group I, 0.45 for Group II, and 0.49 for Group III. Preoperative risk factors associated with a higher mortality included hypertension, smoking, diabetes, and pulmonary hypertension. Two hundred seventy-two of the 299 operative survivors were followed for a mean of 18 (range, 3-52) months. The actuarial survival of octogenarians is 92 per cent, 80 per cent, and 65 per cent at 1, 3, and 5 years, respectively, and of the patients surviving operation it was 85 per cent, 70 per cent, and 55 per cent at 1, 3, and 5 years, respectively. At postoperative follow up, 80 per cent of the survivors reported an active functional status, and there was a low incidence of cardiac-related deaths.
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PMID:Coronary artery bypass and valve replacement in octogenarians. 889 18

All patients undergoing resection of thoracic or thoracoabdominal aneurysms at Mount Sinai Hospital since November 1993 had spinal cord function monitored with somatosensory-evoked potentials as part of a multimodality approach to reducing spinal cord injury. In the segment to be resected, each pair of intersegmental vessels was sequentially clamped, and they were subsequently sacrificed only if no change in somatosensory evoked potentials occurred within 8 to 10 minutes after occlusion. Adjunctive protective measures included mild hypothermia (31 degrees to 33 degrees C), distal perfusion, corticosteroids, maintenance of high normal blood pressures, avoidance of nitroprusside, and cerebrospinal fluid drainage. Ninety-five consecutive patients operated on since 1993 (group II) were compared with 138 earlier patients (group I). Preoperative characteristics such as age, sex, etiology of aneurysm, emergency operation, and reoperation did not differ between groups, nor did operative variables such as incidence of rupture and extent of resection. Group I had slightly more smokers and slightly fewer hypertensive individuals. Group II patients had a significantly better outcome with respect to in-hospital mortality (10.5% vs 18%, p = 0.045) and paraplegia (2% vs 8%, p = 0.008). By multivariate analysis, rupture and diabetes were associated with significantly higher in-hospital mortality, and smoking greatly increased the incidence of paraplegia. The extent of the aneurysm was a major determinant of mortality and paraplegia. The low paraplegia rate in group II was achieved without reattachment of a single intercostal or lumbar artery. No patient with fewer than 10 intersegmental arteries severed had paraplegia, and spinal cord ischemia was reversible in three patients after adjunctive maneuvers were performed to improve perfusion, suggesting that spinal cord blood supply is unlikely to depend on a single "artery of Adamkiewicz."
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PMID:Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta. 891 16

Diabetes mellitus and food deprivation are two conditions known to significantly reduce the ability to generate body heat during periods of acute cold stress. The purpose of this study was to determine if shivering is attenuated in the urethane-anesthetized (1.5 g/kg; i.p.), streptozotocin-induced diabetic (STZ; n = 10) and food-deprived (12-hour nocturnal fast) rat (FD; n = 11) as colonic temperature (Tcol) declined from baseline (36 degrees C) to 28 degrees C. Shivering was assessed using the mean rectified electromyographic (EMG) signal obtained from indwelling bipolar electrodes placed in the gluteus superficialis muscle. Although the mean rectified EMG progressively increased (P < or = 0.05) between Tcol of 33 degrees C to 28 degrees C and achieved peak activity (7.89 +/- 1.80 microV) at 29 degrees C in non-diabetic rats, shivering activity was virtually absent in the STZ group throughout cooling (e.g. peak EMG = 0.49 +/- 0.09 microV). The lack of shivering activity in STZ could partially explain the shorter time to reach 28 degrees C (STZ, 48.5 +/- 1.5 vs CON, 136.5 +/- 23.0 min; P < or = 0.05) and the divergent trends in oxygen consumption (delta VO2) between STZ and non-diabetic rats. In the FD group, the mean peak rectified EMG activity (3.09 +/- 1.35 microV) was significantly lower (P < or = 0.05) than the fed group. The peak delta VO2 from baseline (FD, +2.11 +/- 0.36 vs. CON, +4.51 +/- 0.50 mlO2/min) and the time taken to reach 28 degrees C (FD, 73.4 +/- 4.2 vs CON, 136.5 +/- 23.0 min) were statistically different (P < or = 0.05) between groups. The results indicate that: 1) shivering thermogenesis is severely depressed and hypothermia accelerated in experimental diabetic animals as evidenced by the attenuation in mean rectified EMG and delta VO2, and 2) FD rats experienced a faster decline in colonic temperature than the fed group due, in part, to the relatively greater decline in shivering activity and oxygen consumption.
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PMID:Effects of diabetes and food deprivation on shivering activity during progressive hypothermia in the rat. 892 31

The aim of the study was to validate clinically a new technique of myocardial protection developed for intra- and extra-cardiac surgery on the beating heart. The concept combines the principle of continuous pressure- and volume-controlled coronary artery perfusion (PVC-CONTHY-CAP) with the specific myocardioprotective effects of hypothermia and nitrates and, on the other hand, with the beta-blocker-mediated reduction of chronotropy and inotropy necessary for convenient surgery. Under standard ECC conditions after cross-clamping the aorta coronary perfusion with oxygenated blood enriched with nitroglycerine (10 micrograms/kg/h) and esmolol (0.05 mg/ml flow/min) is started via an additional perfusion cannula placed in the aortic root. The temperature of the perfusate is maintained at 32 degrees C, the intraaortic pressure at 40-70 mmHg and the perfusion flow in the range 0.8-1.0 ml/g heart muscle/min. In CABG procedures an additional perfusion catheter is used for perfusion of distal coronary artery segments. Using this technique 100 consecutive patients, adults and children, were operated on between 2/96 and 8/96. In 84 adult patients (age: 45-82 yrs), 78 CABG procedures (54 elective, 13 urgent, 11 acute) with a mean bypass count of 3.7 (range 1-7), 69 ITA grafts, 72 grafts to CX, and 3 MVRec/MVRpl, and 6 pure MVRec/MVRpl procedures (1 urgent, 1 emergency) were performed. The mean coronary perfusion time was 48 min (range 21-88 min). In 5 patients perioperative infarction (CABG; 1 emergency after PTCA, 4 elective) with significant increase of CK-MB values (57-98 U/L) occurred. In the 4 elective patients (3 with diabetes mellitus) re-intervention was not possible due to small-vessel disease. In one patient with preoperative infarction IABP was necessary. No patient died. There were 16 children (age: 4weeks-16 yrs): VSD, n = 6, AV-C, n = 2, TOF, n = 1, MVRec, n = 1, DORV (Rastelli), n = 2, SV (TCPC), n = 3, and PV obstruction, n = 1. The mean coronary perfusion time was 97 min (range: 27-260 min). The mean ICU stay 3.9 d (range: 1-10 d). One child died (TCPC) on the 10th postoperative day due to multi-organ failure. In conclusion, PVC-CONTHY-CAP is designed especially for emergency and urgent procedures, i.e. patients with PTCA-related complications, patients with severely depressed LV function, and patients with complex congenital cyanotic heart defects. Using PVC-CONTHY-CAP, coronary artery bypass grafting as well as intracardiac procedures for congenital and acquired heart defects can be performed safely and conveniently, the system is easy to handle for both the cardiac surgeon and perfusionist. Due to its pharmacological properties continuous intracoronary application of nitrates in combination with hypothermia seems to be essential as a preventive treatment modality for the ischemic state.
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PMID:Myocardial protection by pressure- and volume-controlled continuous hypothermic coronary perfusion (PVC-CONTHY-CAP) in combination with ultra-short beta-blockade and nitroglycerine. 917 18

The main purpose of intensive insulin therapy in insulin-dependent diabetes mellitus is to prevent complications by maintaining short- and long-term euglycaemia. This therapeutic approach implies a high frequency of hypoglycaemic events which can be disturbing when hypoglycaemia unawareness is involved. Although this phenomenon can be reversed, it may lead to discontinuance of intensive insulin therapy. This paper concerns the case of a young insulin-dependent patient with early onset diabetes who had frequent severe occurrences of hypoglycaemia with convulsions, hypothermia, bradycardia and coma. These events were associated with hypoglycaemia unawareness not due to autonomic neuropathy. A defect in counterregulation was demonstrated during hypoglycaemic-hyperinsulinaemic clamp, expressed as a reduction of adrenaline response. A positive pattern of anti-adrenal medullary antibodies suggested that a functional defect of the adrenal medulla plays a role in the pathogenesis of hypoglycaemia unawareness.
Diabetes Metab 1997 Dec
PMID:Hypoglycaemia unawareness in a young boy with insulin-dependent diabetes mellitus and anti-adrenal medullary antibodies. 949 60

In clinical medicine, severe keto- or lactic acidosis associated with vomiting, nausea, abdominal pain, tachycardia or pathological respiration, has been described in chronic alcoholics. This study reports on fatalities of chronic alcoholics where the cause of death could not be determined by thorough autopsy, histology and toxicology including determination of alcohol concentration. In a first series, acetone was determined in the blood of such chronic alcoholics (n = 24), diabetics with metabolic decompensation (n = 7), cases of hypothermia (n = 7) and controls (n = 218). Among the 24 chronic alcoholics where the cause of death was unknown, 9 cases showed very high levels of acetone (74-400 mg/l). These comprised 6 cases without additional findings and 3 cases where a second patho-mechanism such as intoxication possibly contributed to the cause of death. In a second series, the sum values according to Traub (lactate/glucose) were determined in cerebrospinal liquor of chronic alcoholics with undetermined cause of death (n = 45), diabetics (n = 6) and controls (n = 39). Among the 45 alcoholics, 17 cases showed very high sum values (294-594 mg/dl) including 8 cases where non-lethal intoxications may have contributed to the final outcome. Other causes of a ketoacidosis or lactic acidosis (e.g. diabetes) were excluded in both groups of alcoholics. Consequently, ketoacidosis and lactic acidosis can be the cause of death of chronic alcoholics in a considerable number of cases where no pathomorphological or toxicological changes are present. A scheme for medical and laboratory examination is described.
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PMID:Ketoacidosis and lactic acidosis--frequent causes of death in chronic alcoholics? 958 92

The systemic inflammatory response to cardiopulmonary bypass (CPB) is associated with increased production of cytokines. This systemic inflammatory response characterized by the activation of interleukin-6 (IL-6) and interleukin-8 (IL-8) during and after CPB is well documented. A prospective, randomized, double-blind study was performed so as to understand the effects of low-dose methyl prednisolone sodium succinate (MPSS) on the circulating levels of serum cytokines and clinical outcome. Twenty patients were randomly divided into two groups on the basis of the administration of low-dose (1 mg/kg) MPSS (n = 10) and placebo (n = 10) into the pump prime solution. All patients were scheduled to undergo a primary elective coronary artery bypass grafting operation. Patients receiving concurrent corticosteroids, salicylates, dipyridamol or anticoagulants were excluded from the study. Other exclusion criteria were concurrent chronic obstructive pulmonary disease, chronic renal failure, insulin-dependent diabetes, congestive cardiac failure, peptic ulcer history, prior cardiac operations, recent (in a one-month period) myocardial infarction and steroid dependency. Mild systemic hypothermia (30-32 degrees C, rectal) was assured during the CPB. Four blood samples were drawn from the radial artery catheter immediately before starting CPB (T1), following protamine administration (T2) and at 24 (T3) and 48 h (T4) after completion of CPB. In each sample, creatine kinase-myocardial band (CK-MB), white blood cell (WBC), IL-6 and IL-8 levels were measured. IL-6 and IL-8 concentrations were measured by enzyme immunoassay and enzyme-linked immunoabsorbant assay methods. Serum IL-6 T2 and serum IL-6 T3 levels were significantly higher than IL-6 T1 levels in both groups (p < 0.001) and (p < 0.01), and there was no significant elevation in serum IL-8 levels in either group. Serum IL-6 levels were significantly higher in the placebo group than in the MPSS group at T3 (p < 0.009). There was no significant difference in CK-MB T1 levels between the groups. Although there was no significant difference between CK-MB T1 and T2 levels in the MPSS group, the CK-MB T2 and CK-MB T3 levels were significantly higher than T1 levels in the placebo group (p < 0.001) and (p < 0.05). There was significant elevation of WBC levels at T2 and T3 in both groups without notable difference between the groups (p < 0.05). This study has shown that low-dose MPSS suppresses CPB-induced inflammatory response. Further clinical studies (on larger and higher risk groups) may reveal more information on relations between morbidity and cytokine levels which may have some predictive value on clinical outcome following CPB.
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PMID:Effect of low-dose methyl prednisolone on serum cytokine levels following extracorporeal circulation. 1041 Dec 50

Fetal bradycardia is a recognized response to maternal hypothermia but has not previously been reported in conjunction with diabetes. A 30-year-old insulin-dependent diabetic was admitted at 35 weeks gestation for control of her diabetes. She developed maternal hypothermia and hypoglycemia and the fetal heart rate fell to 100 beats per minute (b.p.m.). However, the fetal heart rate gradually returned to normal after rewarming the patient.
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PMID:The effect of maternal hypothermia on the fetal heart rate. 1046 40

We have investigated the clinical characteristics of renal damage and associated complications of 79 patients with accidental hypothermia whom we encountered over the last 5 years. All patients were male, with an average age of 58.9 +/- 9.2 years. Most of these patients were homeless. Body temperature on admission was 29.3 +/- 3.0 degrees C. The most common clinical manifestations on admission were consciousness disturbance and severe hypotension. Complications, including increase in serum transaminase, alcoholism, pneumonia, liver cirrhosis, sepsis, diabetes mellitus, hypoglycemia, acidosis, and an increased level of serum CPK and amylase were found frequently on admission. Death within 48 hours after admission occurred in 23 cases (the death rate; 23/79 = 29%). Renal damage was found in 36 cases (36/79 = 46%), consisting of acute renal failure (ARF) in 27, and acute on chronic in 6. Urinary diagnostic indices suggested that the etiological factor for ARF was pre-renal, which responded well to passive rewarming and an appropriate fluid replacement therapy, resulting in full recovery in most of the cases (the recovery rate; 25/27 = 93%). Among patients with renal damage, there were no cases requiring dialysis. The present data suggest that accidental hypothermia is a fatal condition with an extremely high death rate. It also is associated with multiple complications including ARF. The main cause for ARF is pre-renal, possibly caused by cold diuresis or dehydration superimposed on the underlying diseases such as alcoholism, diabetes mellitus, liver cirrhosis. Such complications, independent of renal damage, determine the patient's prognosis.
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PMID:[Clinical characteristics of renal damage in patients with accidental hypothermia]. 1050 43


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