Use of Extracorporeal Membrane Oxygenation in Patients with Refractory Cardiac Arrest due to Severe Persistent Hypothermia: About 2 Case Reports and a Review of the Literature

We report the cases of two patients experiencing persistent severe hypothermia. They were 45 and 30 years old and had a witnessed cardiac arrest managed with mechanized cardiopulmonary resuscitation (CPR) for 4 and 2.5 hours, respectively. Extracorporeal membrane oxygenation was used in both patients who fully recovered without any neurological sequelae. These two cases illustrate the important role of extracorporeal CPR (eCPR) in persistent severe hypothermia leading to cardiac arrest.

The Efficacy of Renal Replacement Therapy for Rewarming of Patients in Severe Accidental Hypothermia—Systematic Review of the Literature

Background: Renal replacement therapy (RRT) can be used to rewarm patients in deep hypothermia. However, there is still no clear evidence for the effectiveness of RRT in this group of patients. This systematic review aims to summarize the rewarming rates during RRT in patients in severe hypothermia, below or equal to 32 °C. Methods: This systematic review was registered in the PROSPERO International Prospective Register of Systematic Reviews (identifier CRD42021232821). We searched Embase, Medline, and Cochrane databases using the keywords hypothermia, renal replacement therapy, hemodialysis, hemofiltration, hemodiafiltration, and their abbreviations. The search included only articles in English with no time limit, up until 30 June 2021. Results: From the 795 revised articles, 18 studies including 21 patients, were selected for the final assessment and data extraction. The mean rate of rewarming calculated for all studies combined was 1.9 °C/h (95% CI 1.5–2.3) and did not differ between continuous (2.0 °C/h; 95% CI 0.9–3.0) and intermittent (1.9 °C/h; 95% CI 1.5–2.3) methods (p > 0.9). Conclusions: Based on the reviewed literature, it is currently not possible to provide high-quality recommendations for RRT use in specific groups of patients in accidental hypothermia. While RRT appears to be a viable rewarming strategy, the choice of rewarming method should always be determined by the specific clinical circumstances, the available resources, and the current resuscitation guidelines.

Incidence of Severe Hypothermia and Its Impact on Postoperative Surgical Complications and Time Delay to Adjunct Treatments in Breast Surgery Cancer Patients: A Case-Controlled Study

Introduction: Unintended postoperative hypothermia frequently occurs upon arrival in the post anesthesia care unit (PACU). As part of our quality assurance program in anesthesia, we regularly monitor the incidence of this complication through our anesthesia information management system (AIMS). In this case-controlled retrospective study, our goal was to detect the incidence of unintended severe hypothermia in our breast surgery cancer patients, and subsequently to analyze the consequence of this complication in terms postoperative cutaneous infection, as well as its impact on further complementary treatment, such as radiotherapy and chemotherapy. Methods: This study was a retrospective analysis conducted through our AIMS system from 2015 through 2019, with extraction criteria based on year, type of surgery (breast), and temperature upon arrival in PACU. A tympanic temperature of less than 36 °C was considered to indicate hypothermia. Severe hypothermia was considered for patients having a temperature lower than 35.2 °C (hypothermic) (n = 80), who were paired using a propensity score analysis with a control group (normothermic) (n = 80) of other breast cancer surgery patients. Extracted data included time of surgery, sex, age, ASA status, and type and duration of the intervention. Results: The mean incidence of hypothermia was 21% from 2015 through 2019. The body mass index (BMI) was significantly lower in the hypothermia group before matching, 23.5 ± 4.1 vs. 26.4 ± 6.1 kg/m2 in normothermic patients (p < 0.05). The hypothermia group also had significantly fewer monitoring and active warming devices. No difference was noted for wound complications. Time to complementary chemotherapy and or radiotherapy did not differ between groups (52 ± 21 days in group hypothermia vs 49 ± 22 days in the control group). Conclusion: Severe intraoperative hypothermia remains an important quality assurance issue in our breast surgery cancer patients, but we could not detect any long-term effect of hypothermia.

Bradycardia in a newborn with accidental severe hypothermia: treat or don’t touch? A case report

Background Hypothermia significantly affects mortality and morbidity of newborns. Literature about severe accidental hypothermia in neonates is limited. We report a case of a neonate suffering from severe accidental hypothermia. An understanding of the physiology of neonatal thermoregulation and hypothermia is important to decide on treatment. Case presentation A low-birth-weight newborn was found with severe accidental hypothermia (rectal temperature 25.7 °C) due to prolonged exposure to low ambient temperature. The newborn presented bradycardic, bradypnoeic, lethargic, pale and cold. Bradycardia, bradypnea and impaired consciousness were interpreted in the context of the measured body temperature. Therefore, no reanimation or intubation was initiated. The newborn was closely monitored and successfully treated only with active and passive rewarming. Conclusion Clinical parameters such as heart frequency, blood pressure, respiration and consciousness must be interpreted in light of the measured body temperature. Medical treatment should be adapted to the clinical presentation. External rewarming can be a safe and effective measure in neonatal patients.

Clinical relevance of impaired consciousness in accidental hypothermia: A Japanese multicenter retrospective study

Background This study aimed to investigate the association between level of impaired consciousness and severe hypothermia less than 28°C among accidental hypothermia. Severe accidental hypothermia (AH) is a life-threatening condition, and early identification can enable transport to an appropriate medical facility. The Swiss staging system has been used to classify patients with AH, but little is known regarding the association between the level of impaired consciousness and core body temperature (BT) in AH. This study aimed to clarify the association between level of impaired consciousness and core BT and determine whether the level of impaired consciousness could be used to predict severe hypothermia and in-hospital mortality among patients with AH. Results The study included 505 of 572 patients in the J-point registry. Relative to mildly impaired consciousness (Glasgow coma scale (GCS) 13–15), the adjusted odds ratios for severe hypothermia were moderate (GCS9-12) 3.26 (95% CI: 1.69–6.25) and severe (GCS < 9) 4.68 (95% CI: 2.40–9.14) for severely impaired consciousness. Relative to mildly impaired consciousness (GCS 13–15), the adjusted odds ratios for in-hospital mortality were moderate (GCS9-12) 1.65 (95% CI: 0.95–2.88) and severe (GCS < 9) 2.10 (95% CI: 1.17–3.78). Conclusions The level of impaired consciousness in patients with accidental hypothermia may predict severe hypothermia and in-hospital mortality.

Bradycardia in Accidental Severe Hypothermia in a Newborn: Treat or Don’t Touch? A case report

BackgroundHypothermia significantly affects mortality and morbidity of newborns. Literature about severe accidental hypothermia in neonates is limited. We present a case of a neonate suffering from severe accidental hypothermia. An understanding of the physiology of neonatal thermoregulation and hypothermia is important to decide on treatment.Case presentationWe report a case of severe accidental hypothermia (rectal temperature 25.7°C) in a hypothropic newborn due to prolonged exposure to low ambient temperature. The newborn presented bradycardic, bradypneic, lethargic, pale and cold. Bradycardia, bradypnea and consciousness were interpreted in the context of the measured body temperature. Therefore, no reanimation or intubation was initiated. The newborn was closely monitored and successfully treated only with active and passive rewarming. ConclusionClinical parameters such as heart frequency, blood pressure, respiration and consciousness must be interpreted in light of the measured body temperature. Medical treatment should be adapted to the clinical presentation. External rewarming can be a safe and effective measure in neonatal patients.

Neonatal hypothermia in Northern Uganda: a community-based cross-sectional study

ObjectiveTo determine the prevalence, predictors and case fatality risk of hypothermia among neonates in Lira district, Northern Uganda.SettingThree subcounties of Lira district in Northern Uganda.DesignThis was a community-based cross-sectional study nested in a cluster randomised controlled trial.ParticipantsMother–baby pairs enrolled in a cluster randomised controlled trial. An axillary temperature was taken during a home visit using a lithium battery-operated digital thermometer.Primary and secondary outcomesThe primary outcome measure was the prevalence of hypothermia. Hypothermia was defined as mild if the axillary temperature was 36.0°C to <36.5°C, moderate if the temperature was 32.0°C to <36.0°C and severe hypothermia if the temperature was <32.0°C. The secondary outcome measure was the case fatality risk of neonatal hypothermia. Predictors of moderate to severe hypothermia were determined using a generalised estimating equation model for the Poisson family.ResultsWe recruited 1330 neonates. The prevalence of hypothermia (<36.5°C) was 678/1330 (51.0%, 95% CI 46.9 to 55.1). Overall, 32% (429/1330), 95% CI 29.5 to 35.2 had mild hypothermia, whereas 18.7% (249/1330), 95% CI 15.8 to 22.0 had moderate hypothermia. None had severe hypothermia. At multivariable analysis, predictors of neonatal hypothermia included: home birth (adjusted prevalence ratio, aPR, 1.9, 95% CI 1.4 to 2.6); low birth weight (aPR 1.7, 95% CI 1.3 to 2.3) and delayed breastfeeding initiation (aPR 1.2, 95% CI 1.0 to 1.5). The case fatality risk ratio of hypothermic compared with normothermic neonates was 2.0 (95% CI 0.60 to 6.9).ConclusionThe prevalence of neonatal hypothermia was very high, demonstrating that communities in tropical climates should not ignore neonatal hypothermia. Interventions designed to address neonatal hypothermia should consider ways of reaching neonates born at home and those with low birth weight. The promotion of early breastfeeding initiation and skin-to-skin care could reduce the risk of neonatal hypothermia.Trial registration numberClinicalTrial.gov as NCT02605369.

Cardiac arrest caused by accidental severe hypothermia and myocardial infarction during general anesthesia

Therapeutic hypothermia is often used for traumatic brain injury because of its neuroprotective effect and decreased secondary brain injury. However, this procedure lacks clinical evidence supporting its efficacy, and adverse outcomes have been reported during general anesthesia. A 61-year-old man with a history of percutaneous coronary intervention (PCI) was admitted with traumatic brain injury. Immediately after admission, he underwent mild therapeutic hypothermia with a target temperature of 33.0°C for neuroprotection. During general anesthesia for emergency surgery because he developed a mass effect, hypothermic cardiac arrest occurred following an additional decrease in the core body temperature. Moreover, myocardial infarction caused by restenosis of the previous PCI lesion also contributed to the cardiac arrest. Although the patient recovered spontaneous circulation after an hour-long cardiopulmonary resuscitation with rewarming, he eventually died of subsequent repetitive cardiac arrests. When anesthetizing patients undergoing therapeutic hypothermia, caution is required to prevent adverse outcomes that can be caused by unintentional severe hypothermia and exacerbation of underlying heart disease.