- Profound accidental hypothermia - systematic approach to active recognition and treatment. [JOURNAL ARTICLE]
- ASAIO J 2016 Jul 26.
We sought to organize a functional system of recognition and advanced treatment of hypothermic patients with extracorporeal rewarming as a treatment option. All patients with suspected hypothermia are consulted with the Hypothermia Coordinator (HC), whose role is to provide expertise on hypothermia recognition and treatment to all rescue and medical services. Patients with Swiss Staging System of Hypothermia (HT) class III and IV are subjected to extracorporeal rewarming. Patients with class I and II are managed in local hospitals, after the hypothermia coordinator provides instructions.From program initiation (July 29, 2013) to November 1, 2015, HC consulted 104 hypothermic patients; 21 in HT class III and IV were subjected to extracorporeal rewarming in the John Paul II Hospital in Cracow, Poland. The remaining individuals were rewarmed in the referring hospitals. Cardiac arrest upon referral was present in 10 cases (resuscitation times from arrest to ECMO implantation ranged 107-345 minutes). Seven patients died, the remaining 14 have been rewarmed with the restoration of hemodynamic stability. Systematic approach to active recognition and treatment of profound accidental hypothermia patients, based on HC cooperation with emergency medical services enables advanced management with good outcomes, especially in patients with cardiac arrest.
- The Hand and Foot in the Cold. [Journal Article]
- Phys Sportsmed 1983 Feb; 11(2):156-68.
In brief: Physiological and physical methods were used to study the effects of chilling on the hands and feet and to compare various mittens and footwear. The woolen liner-leather shell mitten is effective protection for the hands, and the woolen sock-felt liner-shoepac combination was good for protecting the feet. Direct contact with the ground greatly increases heat loss, so the thickness of the sole is important. Superficial rewarming of the hand will stimulate blood flow to it, but blood flow will not return to the foot unless the whole body is sufficiently warm. Therefore, torso protection is as important as extremity protection for long exposures.
- Ultrasonography of the internal carotid artery during therapeutic hypothermia. [Journal Article]
- Pediatr Int 2016 Jul; 58(7):666-8.
The purpose of this study was to determine the accuracy of mean blood flow velocity (mean V) in the internal carotid artery (ICA) for prediction of outcome in infants with hypoxic-ischemic encephalopathy (HIE) exposed to therapeutic hypothermia (TH). Five newborns with HIE who met the criteria for TH were enrolled. Ultrasonography of the right and left ICA was performed before, during, and after TH. Mean V of the sampling point in each ICA was measured. Mean V was suppressed during TH and increased after rewarming in four infants with normal neurological development. In one infant with neurological disability, however, mean V increased during TH and decreased after therapy. In conclusion, cervical ultrasonography for ICA in infants during TH may be useful for the prediction of neurodevelopmental outcome.
- Pathogenesis-Related Protein 1b1 (PR1b1) Is a Major Tomato Fruit Protein Responsive to Chilling Temperature and Upregulated in High Polyamine Transgenic Genotypes. [Journal Article]
- Front Plant Sci 2016.:901.
Plants execute an array of mechanisms in response to stress which include upregulation of defense-related proteins and changes in specific metabolites. Polyamines - putrescine (Put), spermidine (Spd), and spermine (Spm) - are metabolites commonly found associated with abiotic stresses such as chilling stress. We have generated two transgenic tomato lines (556HO and 579HO) that express yeast S-adenosylmethionine decarboxylase and specifically accumulate Spd and Spm in fruits in comparison to fruits from control (556AZ) plants (Mehta et al., 2002). Tomato fruits undergo chilling injury at temperatures below 13°C. The high Spd and Spm tomato together with the control azygous line were utilized to address role(s) of polyamines in chilling-injury signaling. Exposure to chilling temperature (2°C) led to several-fold increase in the Put content in all the lines. Upon re-warming of the fruits at 20°C, the levels of Spd and Spm increased further in the fruit of the two transgenic lines, the higher levels remaining stable for 15 days after re-warming as compared to the fruit from the control line. Profiling their steady state proteins before and after re-warming highlighted a protein of ∼14 kD. Using proteomics approach, protein sequencing and immunoblotting, the ∼14-kD protein was identified as the pathogenesis related protein 1b1 (PR1b1). The PR1b1 protein accumulated transiently in the control fruit whose level was barely detectable at d 15 post-warming while in the fruit from both the 556HO and 579HO transgenic lines PR1b1 abundance increased and remained stable till d 15 post warming. PR1b1 gene transcripts were found low in the control fruit with a visible accumulation only on d 15 post warming; however, in both the transgenic lines it accumulated and increased soon after rewarming being several-fold higher on day 2 while in 556HO line this increase continued until d 6 than the control fruit. The chilling-induced increase in PR1b1 protein seems independent of ethylene and methyl jasmonate signaling but may be linked to salicylic acid. We propose that polyamine-mediated sustained accumulation of PR1b1 protein in post-warmed chilled tomato fruit is a pre-emptive cold stress response and possibly a defense response mechanism related to Cold Stress-Induced Disease Resistance (SIDR) phenomenon.
- Nontherapeutic neonatal hypothermia. [Journal Article]
- Paediatr Child Health 2016 May; 21(4):178-80.
The case presented advocates for prolonged resuscitation, and aggressive rewarming in neonates with severe hypothermia (core temperature <32.0°C). The importance of rewarming has not been extensively studied in current guidelines, whereas the importance of cardiopulmonary resuscitation is well established. This abandoned, severely hypothermic (found with temperature of 27.9°C) newborn had an excellent neurological outcome at two years of age with aggressive resuscitation and rewarming techniques initiated at the time of presentation. Active core rewarming with warm saline lavages, intravenous fluids and warm air may be used at a rate of 1.8°C/h to 5.3°C/h according to most guidelines. Rewarming guidelines for asphyxiated infants undergoing therapeutic hypothermic may not be applicable to infants with accidental exposure, as in the present case. The present case of a near-term severely hypothermic infant reinforces the current recommendation of continuing resuscitative measures, irrespective of response to resuscitation, until the infant has been rewarmed.
- Evaluation of dynamic infrared thermography as an alternative to CT angiography for perforator mapping in breast reconstruction: a clinical study. [Journal Article]
- BMC Med Imaging 2016; 16(1):43.
The current gold standard for preoperative perforator mapping in breast reconstruction with a DIEP flap is CT angiography (CTA). Dynamic infrared thermography (DIRT) is an imaging method that does not require ionizing radiation or contrast injection. We evaluated if DIRT could be an alternative to CTA in perforator mapping.Twenty-five patients scheduled for secondary breast reconstruction with a DIEP flap were included. Preoperatively, the lower abdomen was examined with hand-held Doppler, DIRT and CTA. Arterial Doppler sound locations were marked on the skin. DIRT examination involved rewarming of the abdominal skin after a mild cold challenge. The locations of hot spots on DIRT were compared with the arterial Doppler sound locations. The rate and pattern of rewarming of the hot spots were analyzed. Multiplanar CT reconstructions were used to see if hot spots were related to perforators on CTA. All flaps were based on the perforator selected with DIRT and the surgical outcome was analyzed.First appearing hot spots were always associated with arterial Doppler sounds and clearly visible perforators on CTA. The hot spots on DIRT images were always slightly laterally located in relation to the exit points of the associated perforators through the rectus abdominis fascia on CTA. Some periumbilical perforators were not associated with hot spots and showed communication with the superficial inferior epigastric vein on CTA. The selected perforators adequately perfused all flaps.This study confirms that perforators selected with DIRT have arterial Doppler sound, are clearly visible on CTA and provide adequate perfusion for DIEP breast reconstruction.Retrospectively registered at ClinicalTrials.gov with identifier NCT02806518 .
- Endischemic Reconditioning of Liver Allografts: Controlling the Rewarming. [JOURNAL ARTICLE]
- Liver Transpl 2016 Jul 11.
Background Different non-hypothermic preservation modalities have shown beneficial effects in liver transplantation models. This study compares controlled oxygenated rewarming (COR) to Normothermic Machine Perfusion (NMP) to resuscitate liver grafts following cold storage. Methods Porcine livers were preserved for 18 h by cold storage. Prior to reperfusion, the grafts were put on a machine perfusion device (LiverAssist®) for 3 h and were randomly assigned to COR or NMP (n=6, resp.) and compared to standard cold storage. COR was carried out with the new Custodiol-N solution, slowly increasing temperature from 8°C to 20°C during the first 90 min. NMP was carried out with diluted autologous blood at 37°C for 3 h. In both cases the perfusate was oxygenated to pO2>500mmHg. Then liver viability was tested for 180 min during in vitro isolated sanguineous reperfusion. Results Activity of the mitochondrial caspase-9 was lower after COR. Measurement of tissue ATP and TAN (total adenine nucleotides) at the end of the reconditioning period showed better energetic recovery after COR. COR also resulted in significantly lower enzyme leakage and higher bile production (p<0.05) during reperfusion. Conclusion This first comparison of COR and NMP as endischemic reconditioning modalities demonstrates superior results in terms of mitochondrial integrity resulting in better energetic recovery, less hepatocellular injury, and ultimately superior function in favor of COR. This article is protected by copyright. All rights reserved.
- Cardiopulmonary responses during the cooling and the extracorporeal life support rewarming phases in a porcine model of accidental deep hypothermic cardiac arrest. [Journal Article]
- Scand J Trauma Resusc Emerg Med 2016; 24(1):91.
This study aimed to assess cardiac and pulmonary pathophysiological responses during cooling and extracorporeal life support (ECLS) rewarming in a porcine model of deep hypothermic cardiac arrest (DHCA). In addition, we evaluated whether providing a lower flow rate of ECLS during the rewarming phase might attenuate cardiopulmonary injuries.Twenty pigs were cannulated for ECLS, cooled until DHCA occurred and subjected to 30 min of cardiac arrest. In order to assess the physiological impact of ECLS on cardiac output we measured flow in the pulmonary artery using Doppler echocardiography as well as a modified thermodilution technique using the Swan-Ganz catheter (injection site in the right ventricle). The animals were randomized into two groups during rewarming: a group with a low blood flow rate of 1.5 L/min (LF group) and a group with a normal flow rate of 3.0 L/min (NF group). The ECLS temperature was adjusted to 5 °C above the central core. Cardiac output, hemodynamics and pulmonary function parameters were evaluated.During the cooling phase, cardiac output, heart rhythm and blood pressure decreased continuously. Pulmonary artery pressure tended to increase at 32 °C compared to the initial value (20.2 ± 1.7 mmHg vs. 29.1 ± 5.6 mmHg, p = 0.09). During rewarming, arterial blood pressure was higher in the NF than in the LF group at 20° and 25 °C (p = 0.003 and 0.05, respectively). After rewarming to 35 °C, cardiac output was 3.9 ± 0.5 L/min in the NF group vs. 2.7 ± 0.5 L/min in LF group (p = 0.06). At the end of rewarming under ECLS cardiac output was inversely proportional to the ECLS flow rate. Moreover, the ECLS flow rate did not significantly change pulmonary vascular resistance.Using a newly developed experimental model of DHCA treated by ECLS, we assessed the cardiac and pulmonary pathophysiological response during the cooling phase and the ECLS rewarming phase. Despite lower metabolic need during hypothermia, a low ECLS blood flow rate during rewarming did not improved cardiopulmonary injuries after rewarming.A low ECLS flow rate during the rewarming phase did not attenuate pulmonary lesions, increased blood lactate level and tended to decrease cardiac output after rewarming. A normal ECLS flow rate did not increase pulmonary vascular resistance compared to a low flow rate. This experimental model on pigs contributes a number of pathophysiological findings relevant to the rewarming strategy for patients who have undergone accidental DHCA.
- [Effect of Stellate Ganglion Block on Bilateral Regional Cerebral Oxygen Saturation and Postoperative Cognitive Function]. [English Abstract, Journal Article, Randomized Controlled Trial]
- Sheng Wu Yi Xue Gong Cheng Xue Za Zhi 2016 Feb; 33(1):132-5.
The present study was to examine the effect of stellate ganglion block (SGB) on bilateral regional cerebral oxygen saturation (rSO2) and postoperative cognitive function. Eighty patients undergoing selective coronary artery bypass graft with cardiopulmonary bypass (CPB) were randomly and equally divided into two groups. The patients in group S were given right SGB with ropivacaine, while the patients in group C were injected with normal saline. We compared the bilateral rSO2 after SGB. Minimum Mental State Examination (MMSE), Visual Verbal Learning Test (VVLT), and Digital Span Test (DST) were applied to observe the effect on cognitive function. We found that the incidence of postoperative cognitive dysfunction (POCD) 7 days after surgery in group S was lower than that in group C. The level of blocked side rSO₂ of S group were significantly higher before CPB time of rewarming than that before SGB (P < 0.05), much higher than corresponding non-blocked side rSO₂ before CPB (P < 0.05), and much higher than rSO₂ level in group C before CPB and after CPB (P < 0.05). The non-blocked side rSO₂ in group S before anesthesia were much lower than basic levels and those in group C (P < 0.05). It could be concluded from the above results that there was significant increase in the blocked-side rSO₂ compared to the non-blocked side and there was significant decrease in the incidence of POCD compared to the control group after SGB.
- Catheter-Directed Intraarterial Thrombolysis as Part of a Multidisciplinary Management Protocol of Frostbite Injury. [Journal Article]
- J Vasc Interv Radiol 2016 Aug; 27(8):1228-35.
To evaluate intraarterial catheter-directed thrombolysis for prediction and prevention of delayed surgical amputation as part of multidisciplinary management of frostbite injury.A retrospective review was performed of 13 patients (11 men, 2 women; median age, 33.4 y; range, 8-62 y) at risk of tissue loss secondary to frostbite injury and treated with catheter-directed tissue plasminogen activator (t-PA) thrombolysis. Amputation data were assessed on follow-up (mean, 23 mo; range, 9-83 mo). Angiographic findings were classified into complete, partial, and no angiographic response and assessed for association with follow-up amputation rates. Correlation between amputation outcome and duration of cold exposure (mean, 23 h; range, 5-96 h), time between exposure and rewarming therapy (mean, 25.5 h; range, 7-95 h), and time between exposure and t-PA thrombolysis (mean, 32 h; range, 12-96 h) was assessed. Complications were recorded.Of 127 digits at risk on baseline angiography that were treated with catheter-directed thrombolysis, complete recovery was seen in 106 (83.4%). Total mean t-PA dose per extremity was 27.5 mg (range, 12-48 mg) over a mean period of 34 hours (range, 12-72 h). Patients with complete angiographic response (8 patients; 79.5% of digits) did not require amputations; 4 of 5 patients (80%) with partial angiographic response (20.5% of digits) underwent amputation (P = .007). There was no significant correlation between amputation rates and duration of cold exposure (P = .9), time to rewarming therapy (P = .88), and time to thrombolysis (P = .56). Femoral access site bleeding in 2 patients was managed conservatively. One patient underwent surgical exploration for brachial artery hematoma.Intraarterial catheter-directed thrombolysis should be included in initial management of frostbite injury, as it may prevent delayed amputations. The degree of angiographic response to thrombolysis can potentially predict amputation outcomes.