Is oxygen supply a limiting factor for survival during rewarming from profound hypothermia?

It has been postulated that unsuccessful resuscitation of victims of accidental hypothermia is caused by insufficient tissue oxygenation. The aim of this study was to test whether inadequate O2 supply and/or malfunctioning O2 extraction occur during rewarming from deep/profound hypothermia of different duration. Three groups of rats (n = 7 each) were used: group 1 served as normothermic control for 5 h; groups 2 and 3 were core cooled to 15 degrees C, kept at 15 degrees C for 1 and 5 h, respectively, and then rewarmed. In both hypothermic groups, cardiac output (CO) decreased spontaneously by > 50% in response to cooling. O2 consumption fell to less than one-third during cooling but recovered completely in both groups during rewarming. During hypothermia, circulating blood volume in both groups was reduced to approximately one-third of baseline, indicating that some vascular beds were critically perfused during hypothermia. CO recovered completely in animals rewarmed after 1 h (group 2) but recovered to only 60% in those rewarmed after 5 h (group 3), whereas blood volume increased to approximately three-fourths of baseline in both groups. Metabolic acidosis was observed only after 5 h of hypothermia (15 degrees C). A significant increase in myocardial tissue heat shock protein 70 after rewarming in group 3, but not in group 2, indicates an association with the duration of hypothermia. Thus mechanisms facilitating O2 extraction function well during deep/profound hypothermia, and, despite low CO, O2 supply was not a limiting factor for survival in the present experiments.     

Effect of hypothermia on cell kinetics and response to hyperthermia and X rays

Hyperthermia is a potent radio enhancer. Studies using hypothermia in combination with irradiation have given confusing results due to lack of uniformity in experimental design. This report shows that hypothermia might have potential significance in the treatment of malignant cells with both thermo- and radiotherapy. Reuber H35 hepatoma cells, clone KRC-7 were used to study the effect of hypothermia on cell kinetics and subsequent response to hyperthermia and/or X rays. Cells were incubated at 8.5 degrees C or between 25 and 37 degrees C for 24 hr prior to hyperthermia or irradiation. Hypothermia caused sensitization to both hyperthermia and X rays. Maximum sensitization was observed between 25 and 30 degrees C and no sensitization was found at 8.5 degrees C. At 25 degrees C maximum sensitization was achieved in approximately 24 hr, cell proliferation was almost completely blocked, and cells gradually accumulated in the G2 phase of the cell cycle. In contrast to the effect of hypothermia on either hyperthermia or X rays alone, thermal radiosensitization was decreased in hypothermically pretreated cells (24 hr at 25 degrees C) compared to control cells (37 degrees C). The expression of thermotolerance and the rate of development at 37 degrees C after an initial heating at 42.5 degrees C were not influenced after preincubation at 25 degrees C for 24 hr. The expression of thermotolerance for heat or heat plus X rays during incubation at 41 degrees C occurred in a significantly smaller number of cells after 24 hr preincubation at 25 degrees C. The enhanced thermo- and radiosensitivity in hypothermically treated cells disappeared in approximately 6 hr after return to 37 degrees C.     

Peptide hydrolase activity in brain tissues during the early stages of post-hypothermia period

The acid peptidohydrolase activity in the homogenate, dissoluble and mitochondrial-lysosomal fractions of brain tissues of rats who have endured deep hypothermia was determined after their "active" warming for an hour and on the 1st, 2nd, 3d and 7th days after their self-warming. The "active" warming of rats who have endured deep hypothermia (19-20 degrees C) brings about the restoration of the acid peptidohydrolase activity in the subcellular brain tissue fractions. After self-warming the examined enzyme activity restores 7 days later. In the dynamics of the posthypothermic period a change in the acid peptide hydrolase distribution in fractions occurs on the 2nd-3d days.     

Effects of hypothermia and re-warming on the inflammatory response in a murine multiple hit model of trauma

INTRODUCTION: Although, hypothermia is a frequent event after trauma, it is unclear whether its beneficial or detrimental effects are more important. This study aims to quantify the effects of hypothermia and re-warming on the inflammatory response after fracture/hemorrhage and subsequent fracture stabilization with resuscitation. MATERIALS AND METHODS: Eighty-one male C57Bl/6 mice (aged 8-10 weeks, weighing 22.0+/-3.0 g) underwent femoral fracture and hemorrhage followed by resuscitation and splint fixation of the fracture. Animals were sacrificed 3h after induction of hemorrhage and fracture. Besides a sham group (n=6), four experimental groups were created: A: normothermia (n=12), B: hypothermia after trauma (n=21), C: re-warming after resuscitation and before stabilization (n=21), and D: hypothermia before trauma (n=21). Groups B-D were further subdivided into three subgroups according to the degree of hypothermia (subgroup 1: 35-33 degrees C, subgroup 2: 32.9-30.0 degrees C, and subgroup 3: 29.9-27.0 degrees C). Plasma cytokine (TNF-alpha, IL-6, and IL-10) and chemokine (MCP-1) concentrations were determined by ELISA, pulmonary permeability changes were quantified, and histological analysis of lung and liver tissues was performed. RESULTS: Normothermia resulted in a significantly increased early mortality rate. A significantly increased pro-inflammatory and decreased anti-inflammatory responses were also observed in normothermia as compared to hypothermia. The extent of these changes was most pronounced in the severe hypothermic group. Re-warming after mild hypothermia resulted in a pro-inflammatory response comparable to normothermia. CONCLUSION: Hypothermia has a beneficial effect on early survival after trauma, which appears to be independent of the level of hypothermia and re-warming. Re-warming, however, enhanced the pro-inflammatory response. Further studies with a longer posttraumatic observation period are required to investigate the long term effects of the hypothermia and re-warming-induced changes on the pro- and anti-inflammatory responses.     

Accidental deep hypothermia with cardiac arrest. Prompt complete recovery after rewarming by extracorporeal circulation. Case report

BACKGROUND: Deep accidental hypothermia (core temperature <28 degrees C) is an uncommon medical emergency requiring rapid active core rewarming. Extracorporeal circulation has become the treatment of choice for deep hypothermic patients with cardiac arrest. CASE REPORT: We report on a 30-year-old patient who suffered from deep accidental hypothermia (core temperature 24.8 degrees C) and cardiac arrest by prolonged exposure to a cold urban environment as a consequence of severe ethylalcohol intoxication. The rewarming with the aid of extracorporeal circulation was initiated shortly after his arrival at the hospital. External cardiac massage was maintained until full ECC fl ow was established. The patient was weaned from extracorporeal circulation after 157 min, awaked 4 hours later and consequently extubated within 16 hours after rewarming with no neurological impairment. At 3-week follow-up, the patient was fully re-integrated in his work and personal life. CONCLUSION: This case demonstrates the excellent prognosis of a young victim in the case of deep accidental hypothermia with cardiac arrest, provided that deep hypothermia precedes the cardiac arrest and rewarming by extracorporeal circulation is immediately applied. Simultaneous ethyl alcohol intoxication can be considered a protective factor improving the patient's outcome. Complete recovery was achieved within 24 hours after the accident.     

Resuscitation from cardiopulmonary arrest during accidental hypothermia due to exhaustion and exposure.

A 16-year-old boy with accidental hypothermia and cardiopulmonary arrest due to exhaustion and exposure was resuscitated after warming measures -- hot wet towels, hot water bottles, and hot water enemas and gastric lavage -- had increased his rectal temperature from 25.2 to 28.0 degrees C. Despite prolonged cardiopulmonary arrest, recovery was almost complete, with no evident cerebral damage. Cardiopulmonary resuscitation procedures should not be abandoned until the body temperature is more than 30 degrees C, because the prognosis in cases of accidental hypothermia without associated disease is excellent if cardiac function can be re-established.     

Effects of cold and capsaicin desensitization on prostaglandin E hypothermia in rats

Intraperitoneal injection of prostaglandin E1 (PGE) produces a transient hypothermia in rats that lasts 1-2 h. Rats exposed to an ambient temperature (Ta) of 26 degrees C displayed a decrease in rectal temperature (Tre) of 0.95 +/- 0.12 degrees C (SE) after injection with PGE (100 micrograms/kg ip). Hypothermia was produced mainly by heat losses, as indicated by increases in tail blood flow. At Ta of 4 degrees C, PGE produced a comparable fall in Tre of 1.00 +/- 0.14 degrees C. However, in the cold the hypothermia was caused solely by decreases in heat production. These results indicate that the PGE-induced hypothermia is not the result of a peripheral vasodilation induced by the direct action of PGE on the tail vascular smooth muscle but is a central nervous system-mediated response of the thermoregulatory system induced by PGE within the peritoneal cavity. Capsaicin injected subcutaneously induces a transient hypothermia in rats because of stimulation of the warm receptors. If administered peripherally in sufficient amounts, it is reputed to impair peripheral warm receptors so that they become desensitized to the hypothermic effects of capsaicin. We measured PGE-induced hypothermias in rats both before and after capsaicin desensitization at Ta of 26 degrees C. Before desensitization the hypothermia was -1.14 +/- 0.12 degrees C, whereas after capsaicin treatment the PGE-induced hypothermia was -0.34 +/- 0.17 degrees C. The biological effects of capsaicin are diverse; however, based on current thinking about the thermoregulatory effects of capsaicin desensitization, our results indicate that peripheral warm receptor pathways are in some manner implicated in the hypothermia induced by intraperitoneal PGE.     

Sensitivity to bile salts of Shigella flexneri sublethally heat stressed in buffer or broth.

Batch cultures of Shigella flexneri M4243 were grown at 37 degrees C in broth to early stationary phase, washed, and heated at 50 degrees C in 0.1 M phosphate buffer (pH 7.0). Cells were surface plated on a tryptic phytone glucose agar (TPGA), TPGA with 0.15 or 0.85% bile salts no. 3 (TPGA-BS 0.15 or TPGA-BS 0.85), or TPGA with 0.25 or 0.50% sodium deoxycholate (TPGA-DC 0.25 or TPGA-DC 0.50). Cells sampled after no heating produced colony counts on TPGA-BS 0.85 or on TPGA-DC 0.50 that were no more than about 0.5 log lower than for unheated cell samples plated on TPGA. Cells heated at 50 degrees C for 30 min produced colony counts on TPGA-DC 0.50 or on TPGA-BS 0.85 that were about 1.5 logs lower than on TPGA. Cells heated for 30 min and shifted to TPG broth at 37 degrees C to allow resuscitation required about 2 h to regain tolerance to 0.85% BS. However, heated cells resuscitated on solid TPGA at 35 degrees C before being challenged with overlays of TPGA-BS 0.85 or TPGA-DC 0.50 required 6 to 8 h on TPGA to regain tolerance to 0.85% BS or 0.50% DC. To regain tolerance to overlays of 0.15% BS or 0.25% DC, heated cells required resuscitation periods on TPGA of about 2 or 2 to 6 h, respectively. Cells heated in TPG broth and sampled after no heating produced colony counts on TPGA that were about 1.5 logs lower than for unheated cell suspensions, suggesting greater apparent injury when heat stressed in broth than in buffer.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sensitivity to bile salts of Shigella flexneri sublethally heat stressed in buffer or broth

Batch cultures of Shigella flexneri M4243 were grown at 37 degrees C in broth to early stationary phase, washed, and heated at 50 degrees C in 0.1 M phosphate buffer (pH 7.0). Cells were surface plated on a tryptic phytone glucose agar (TPGA), TPGA with 0.15 or 0.85% bile salts no. 3 (TPGA-BS 0.15 or TPGA-BS 0.85), or TPGA with 0.25 or 0.50% sodium deoxycholate (TPGA-DC 0.25 or TPGA-DC 0.50). Cells sampled after no heating produced colony counts on TPGA-BS 0.85 or on TPGA-DC 0.50 that were no more than about 0.5 log lower than for unheated cell samples plated on TPGA. Cells heated at 50 degrees C for 30 min produced colony counts on TPGA-DC 0.50 or on TPGA-BS 0.85 that were about 1.5 logs lower than on TPGA. Cells heated for 30 min and shifted to TPG broth at 37 degrees C to allow resuscitation required about 2 h to regain tolerance to 0.85% BS. However, heated cells resuscitated on solid TPGA at 35 degrees C before being challenged with overlays of TPGA-BS 0.85 or TPGA-DC 0.50 required 6 to 8 h on TPGA to regain tolerance to 0.85% BS or 0.50% DC. To regain tolerance to overlays of 0.15% BS or 0.25% DC, heated cells required resuscitation periods on TPGA of about 2 or 2 to 6 h, respectively. Cells heated in TPG broth and sampled after no heating produced colony counts on TPGA that were about 1.5 logs lower than for unheated cell suspensions, suggesting greater apparent injury when heat stressed in broth than in buffer.(ABSTRACT TRUNCATED AT 250 WORDS)     

Rewarming from severe accidental hypothermia with circulatory arrest

This case report demonstrates successful cardiopulmonary and cerebral resuscitation (CPCR) of a young male explored 15 hours following a suicide attempt (carbamazepine intoxication) in deep hypothermia (19 degrees C) with circulatory arrest. An extracorporeal circuit was used to rewarm the patient's blood. Weaning from extracorporeal circulation (ECC) was successful and without complications as was recovery from multiorgan dysfunction, severe rhabdomyolysis and carbamazepine intoxication. An excellent outcome was achieved without any neurological deficit at the time of discharge from the hospital.     

Blood gases in craniocerebral hypothermia

Experiments were conducted on dogs; cranio-cerebral hypothermia (a reduction of body temperature from 38 to 28 degrees C) led to increase of oxygen and to reduction of carbon dioxide tension in the blood. In case of marked hypothermia (24 degrees C) the blood gaseous concentration became less than at 28 degrees C, but remained above the initial level. This indicates prolonged preservation of adequate lung ventilation in the hypothermic organism.     

Cultured Chinese hamster cells undergo apoptosis after exposure to cold but nonfreezing temperatures

Cultured Chinese hamster V79 fibroblast cells at the transition from logarithmic to stationary growth have been shown to undergo apoptosis (programmed cell death) after cold shock [B. L. Soloff, W. A. Nagle, A. J. Moss, Jr., K. J. Henle, and J. T. Crawford, Biochem. Biophys. Res. Commun. 145, 876-883 (1987)]. In this report, we show that about 95% of the cell population was susceptible to cold-induced apoptosis, and the amount of cell killing was dependent on the duration of hypothermia. Cells treated for 0-90 min at 0 degrees C exhibited an exponential survival curve with a D0 of 32 min; thus, even short exposures to the cold (e.g., 5 min) produced measurable cell killing. The cold-induced injury was not produced by freezing, because similar results were observed at 6 degrees C, and cell killing was not influenced by the cryoprotective agent dimethyl sulfoxide. Cold-induced apoptosis was inhibited by rewarming at 23 degrees C, compared to 37 degrees C, by inhibitors of macromolecular synthesis, such as cycloheximide, and by 0.8 mM zinc sulfate. The results suggest that apoptosis represents a new manifestation of cell injury after brief exposure to 0-6 degrees C hypothermia.     

Hypothermia in the elderly: scope for prevention.

Concern is growing about the number of elderly people dying of hypothermia. A register was compiled of patients over 75 on a general practitioner''s list who were identified from their medical records as being at risk of hypothermia, having two or more established risk factors. Twenty four patients from this register were visited early in winter by a doctor to discuss how hypothermia could be prevented. They were then revisited during very cold weather to see whether they had made any changes. Several improvements to heating arrangements were noted, but the median temperature in the bedrooms of houses with no central heating was 10 degrees C below the World Health Organisation''s recommended temperature. In addition, eight patients were not visited daily. Even with media publicity and visits from carers and a doctor, 17 of the 24 elderly people studied continued to live in an environment in which they were at risk of developing hypothermia.     

Effects of subanesthetic doses of inert gases on behavioral thermoregulation in mice

Mice exposed to subanesthetic partial pressures of N2O (0.25 to 0.75 atm) or N2 (5.7 or 11.33 atm) and allowed to choose between a warm and a cool environment showed a marked preference for the cooler environment. This behavior was associated with the onset of hypothermia, with deep body temperature falling by up to about 3 degrees C, usually to a new, steady level. Both the length of time spent in the cooler environment and the degree of the hypothermia produced increased with the partial pressure of N2O or N2 used. The effects of N2O on behavioral thermoregulation and body temperature were reversible. There was a correlation between anesthetic potency and the ability of both gases to alter thermoregulation, suggesting that the effect of these agents on thermoregulation was caused by the same molecular interactions as those which underlie anesthesia. Since both gases elicited changes in behavioral thermoregulation promoting rather than opposing the onset of hypothermia, it is concluded that they may have acted to lower the level at which deep body temperature was being regulated.     

Growth and thermal inactivation of Listeria monocytogenes in cabbage and cabbage juice

Studies were done to determine the interacting effects of pH, NaCl, temperature, and time on growth, survival, and death of two strains of Listeria monocytogenes. Viable population of the organism steadily declined in heat-sterilized cabbage stored at 5 degrees C for 42 days. In contrast, the organism grew on raw cabbage during the first 25 days of a 64-day storage period at 5 degrees C. Growth was observed in heat-sterilized unclarified cabbage juice containing less than or equal to 5% NaCl and tryptic phosphate broth containing less than or equal to 10% NaCl. Rates of thermal inactivation increased as pH of clarified cabbage juice heating medium was decreased from 5.6 to 4.0. At 58 degrees C (pH 5.6), 4 X 10(6) cells/mL were reduced to undetectable levels within 10 min. Thermal inactivation rates in clarified cabbage juice (pH 5.6) were not significantly influenced by the presence of up to 2% NaCl; however, heat-stressed cells had increased sensitivity to NaCl in tryptic soy agar recovery medium. Cold enrichment of heat-stressed cells at 5 degrees C for 21 days enhanced resuscitation. Results indicate that L. monocytogenes can proliferate on refrigerated (5 degrees C) raw cabbage which, in turn, may represent a hazard to health of the consumer. Heat pasteurization treatments normally given to cabbage juice or sauerkraut would be expected to kill any L. monocytogenes cells which may be present.     

Selective enrichment with a resuscitation step for isolation of freeze-injured Escherichia coli O157:H7 from foods

We studied injury of Escherichia coli O157:H7 cells in 11 food items during freeze storage and methods of isolating freeze-injured E. coli O157:H7 cells from foods. Food samples inoculated with E. coli O157:H7 were stored for 16 weeks at -20 degrees C in a freezer. Noninjured and injured cells were counted by using tryptic soy agar and sorbitol MacConkey agar supplemented with cefixime and potassium tellurite. Large populations of E. coli O157:H7 cells were injured in salted cabbage, grated radish, seaweed, and tomato samples. In an experiment to detect E. coli O157:H7 in food samples artificially contaminated with freeze-injured E. coli O157:H7 cells, the organism was recovered most efficiently after the samples were incubated in modified E. coli broth without bile salts at 25 degrees C for 2 h and then selectively enriched at 42 degrees C for 18 h by adding bile salts and novobiocin. Our enrichment method was further evaluated by isolating E. coli O157:H7 from frozen foods inoculated with the organism prior to freezing. Two hours of resuscitation at 25 degrees C in nonselective broth improved recovery of E. coli O157:H7 from frozen grated radishes and strawberries, demonstrating that the resuscitation step is very effective for isolating E. coli O157:H7 from frozen foods contaminated with injured E. coli O157:H7 cells.     

Sustained hypothermia accelerates microvascular thrombus formation in mice

Cold is supposed to be associated with alterations in blood coagulation and a pronounced risk for thrombosis. We studied the effect of clinically encountered systemic hypothermia on microvascular thrombosis in vivo and in vitro. Ferric chloride-induced microvascular thrombus formation was analyzed in cremaster muscle preparations from hypothermic mice. Additionally, flow cytometry and Western blot analysis was used to evaluate the effect of hypothermia on platelet activation. To test whether preceding hypothermia predisposes for enhanced thrombosis, experiments were repeated after hypothermia and rewarming to 37 degrees C. Control animals revealed complete occlusion of arterioles and venules after 742 +/- 150 and 824 +/- 172 s, respectively. Systemic hypothermia of 34 degrees C accelerated thrombus formation in arterioles and venules (279 +/- 120 and 376 +/- 121 s; P < 0.05 vs. 37 degrees C). This was further pronounced after cooling to 31 degrees C (163 +/- 57 and 281 +/- 71 s; P < 0.05 vs. 37 degrees C). Magnitude of thrombin receptor activating peptide (TRAP)-induced platelet activation increased with decreasing temperatures, as shown by 1.8- and 3.0-fold increases in mean fluorescence after PAC-1 binding to glycoprotein (GP)IIb-IIIa and 1.6- and 2.9-fold increases of fibrinogen binding on incubation at 34 degrees C and 31 degrees C. Additionally, tyrosine-specific protein phosphorylation in platelets was increased at hypothermic temperatures. In rewarmed animals, kinetics of thrombus formation were comparable to those in normothermic controls. Concomitantly, spontaneous and TRAP-enhanced GPIIb-IIIa activation did not differ between rewarmed platelets and those maintained continuously at 37 degrees C. Moderate systemic hypothermia accelerates microvascular thrombosis, which might be mediated by increased GPIIb-IIIa activation on platelets but does not cause predisposition with increased risk for microvascular thrombus formation after rewarming.     

Effectiveness of neonatal transport.

The condition of 259 infants transferred to the neonatal intensive care unit (NICU) of the Montreal Children''s Hospital from Oct. 1, 1974 to Mar. 31, 1975 was evaluated. Their transport was provided by personnel and equipment from the Montreal Children''s Hospital. When the transport team arrived at the referring hospital hypothermia (temperature of less than 36 degrees C) was present in 25.2% of the 163 infants for whom complete temperature measurements were available. Most (77.3%) of the infants were warmed during transport and only 3.1% arrived at the NICU with a temperature of less than 35 degrees C. The mortality was significantly higher in babies of all birth weight groups whose core temperature had been below the optimal temperature for survival (36 to 37 degrees C). It appears that the use of appropriate equipment and trained personnel can reduce the incidence of hypothermia and therefore the mortality in infants requiring transfer.     

Hypothermia: teratogenic and protective effects on the development of mouse embryos in vitro

Hypothermia often occurs in association with clinical conditions involving severe hypoglycemia, but its effect on embryonic development has not been well evaluated. Thus, the whole embryo culture method was used to expose day 9 (neurulating) and day 10 (early limb bud stage) mouse embryos to physiologic levels of hypothermia (35 degrees C and 32 degrees C) for 4 and 24 hr. Embryos were evaluated after 24 hours for growth and malformations and compared with controls grown at 37 degrees C. Lactate production was measured in embryos cultured for 4 hr at 32 degrees C and compared with those cultured at 37 degrees C. A 4-hr exposure to hypothermia produced little effect morphologically but reduced the rate of lactate production at both embryonic stages. A 24-hr exposure to hypothermia at 35 degrees C or 32 degrees C produced growth retardation and dysmorphogenesis in embryos undergoing neurulation. Early limb bud stage embryos were less sensitive to this treatment, with growth retardation produced only at the lower temperature. Since hypothermia is commonly associated with severe hypoglycemia in cases of diabetic insulin overdose, day 9 (neurulating) mouse embryos were exposed concurrently to short periods of hypothermia and hypoglycemia and compared with embryos cultured in hypoglycemic medium at normal temperature. The results demonstrate that hypothermia partially protects embryos against the dysmorphogenic effects of hypoglycemia. A balance of metabolic rate and available substrate is discussed as a possible mechanism for this protective effect.