THE combination of anesthetic-induced impairment of thermoregulatory control and exposure to a cool operating room environment makes most surgical patients hypothermic. Several prospective, randomized trials have demonstrated various hypothermia-induced complications. There is no widely accepted definition for the term mild hypothermia. Furthermore, the term is not even used consistently in the literature. For the purpose of this review, mild hypothermia refers to core temperatures between 34 and 36°C.

/pdf/complications-and-treatment-of-mild-hypothermia-4pddmqzdlm.pdf

Complications and treatment of mild hypothermia

The triad of hypothermia, acidosis, and coagulopathy in critically injured patients is a vicious cycle that, if uninterrupted, is rapidly fatal. During the past 7.5 years, 200 patients were treated with unorthodox techniques to abruptly terminate the laparotomy and break the cycle. One hundred seventy patients (85%) suffered penetrating injuries and 30 (15%) were victims of blunt trauma. The mean Revised Trauma Score, Injury Severity Score, and Trauma Index Severity Score age combination index predicted survival were 5.06%, 33.2%, and 57%, respectively. Resuscitative thoracotomies were performed in 60 (30%) patients. After major sources of hemorrhage were controlled, the following clinical and laboratory mean values were observed: red cell transfusions--22 units, core temperature--32.1 C, and pH--7.09. Techniques to abbreviate the operation included the ligation of enteric injuries in 34 patients, retained vascular clamps in 13, temporary intravascular shunts in four, packing of diffusely bleeding surfaces in 171, and the use of multiple towel clips to close only the skin of the abdominal wall in 178. Patients then were transported to the surgical intensive care unit for vigorous correction of metabolic derangements and coagulopathies. Ninety-eight patients (49%) survived to undergo planned reoperation (mean delay 48.1 hours), and 66 of 98 (67%) survived to leave the hospital. With the exception of intravascular shunts, there were survivors who were treated by each of the unorthodox techniques. Of 102 patients who died before reoperation 68 (67%) did so within 2 hours of the initial procedure. Logistic regression showed that red cell transfusion rate and pH may be helpful in determining when to consider abbreviated laparotomy. The authors conclude that patients with hypothermia, acidosis, and coagulopathy are at high risk for imminent death, and that prompt termination of laparotomy with the use of the above techniques is a rational approach to an apparently hopeless situation.

Abbreviated laparotomy and planned reoperation for critically injured patients.

Advances in prehospital care and trauma resuscitation have enabled the early survival of many injured patients who previously had a high chance of dying at the accident scene or en route to the hospital. The change in the spectrum of injury severity, characterized by high-energy blunt trauma with multiple-organ injury and fractures, and the emergence of semiautomatic handguns with multiple penetrating wounds, present new challenges to all surgeons. In conventional trauma care, definitive control and repair of all injuries may be accomplished in the immediate postinjury setting; however, the physiologic derangements of the massive shock state caused by the aforementioned injury patterns often lead to a fully repaired but dead patient. In response to these catastrophic challenges, the concept of “damage control” as a treatment merely to control but not definitively repair injuries has arisen. This term was originally coined by the United States Navy, in reference to “the capacity of a ship to absorb damage and maintain mission integrity.” 1 In the patient with multiple injuries who is exsanguinating, this has been paraphrased to indicate the sum total of the maneuvers necessary to ensure patient survival above all else. 2

Damage control: collective review.

Background Recombinant coagulation factor VIIa (FVIIa) is approved for treating hemophiliacs with inhibitors. High-dose FVIIa has also been used off-label to manage hemorrhage in trauma and surgical patients, many of whom also develop hypothermia and acidosis.Methods We examined the activity of FVII

The effect of temperature and pH on the activity of factor VIIa: implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients

Induced hypothermia can be used to protect the brain from post-ischemic and traumatic neurological injury. Potential clinical applications and the available evidence are discussed in a separate paper. This review focuses on the practical aspects of cooling and physiological changes induced by hypothermia, as well as the potential side effects that may develop. These side effects can be serious and, if not properly dealt with, may negate some or all of hypothermia's potential benefits. However, many of these side effects can be prevented or modified by high-quality intensive care treatment, which should include careful monitoring of fluid balance, tight control of metabolic aspects such as glucose and electrolyte levels, prevention of infectious complications and various other interventions. The speed and duration of cooling and rate of re-warming are key factors in determining whether hypothermia will be effective; however, the risk of side effects also increases with longer duration. Realizing hypothermia's full therapeutic potential will therefore require meticulous attention to the prevention and/or early treatment of side effects, as well as a basic knowledge and understanding of the underlying physiological and pathophysiological mechanisms. These and other, related issues are dealt with in this review.

/pdf/application-of-therapeutic-hypothermia-in-the-intensive-care-3abc751w9t.pdf

Application of therapeutic hypothermia in the intensive care unit. Opportunities and pitfalls of a promising treatment modality--Part 2: Practical aspects and side effects.

Hypothermia in trauma patients is generally considered an ominous sign, although the actual temperature at which hypothermia affects survival is ill defined. In this study, the impact of body core hypothermia on outcome in 71 adult trauma patients with Injury Severity Scores (ISS) greater than or equal to 25 was analyzed. Forty-two per cent of the patients had a core temperature (Tc) below 34 degrees C, 23% below 33 degrees C, and 13% below 32 degrees C. The mortality of hypothermia patients was consistently greater than those who remained warm, regardless of index core temperature. Mortality if Tc less than 34 degrees C = 40%, less than 33 degrees C = 69%, less than 32 degrees C = 100%, whereas mortality if Tc greater than or equal to 34 degrees C = 7%, and greater than or equal to 32 degrees C = 10%. Mortality and the incidence of hypothermia increased with higher ISS, massive fluid resuscitation, and the presence of shock. Within each subgroup (i.e., greater ISS, massive fluid administration, shock) the mortality of hypothermic patients was significantly higher than those who remained warm. No patient whose core temperature fell below 32 degrees C survived.

Hypothermia in Trauma Victims: An Ominous Predictor of Survival

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Hypothermia in Trauma Victims: An Ominous Predictor of Survival