title: Epidural anesthesia increases apparent leg temperature and decreases the shivering threshold.
abstract: BACKGROUND
  Lower core temperatures than usual are required to trigger shivering during epidural and spinal anesthesia, but the etiology of this impairment remains unknown. In this investigation, we propose and test a specific mechanism by which a peripheral action of regional anesthesia might alter centrally mediated thermoregulatory responses. Conduction anesthesia blocks all thermal sensations; however, cold signals are disproportionately affected because at typical leg temperatures mostly cold receptors fire tonically. It thus seems likely that epidural and spinal anesthesia increase the leg temperature perceived by the thermoregulatory system. Because skin temperature reportedly contributes 5-20% to thermoregulatory control, increased apparent (as distinguished from actual) leg temperature would produce a complimentary decrease in the core temperature triggering thermoregulatory shivering. Accordingly, we tested the hypothesis that abnormal tolerance for hypothermia during epidural anesthesia coincides with an increase in apparent leg temperature. We defined apparent temperature as the leg-skin temperature required to induce a reduction in the shivering threshold comparable to that produced by epidural anesthesia.
  
  
  METHODS
  Six women were studied on 4 randomly ordered days: (1) leg-skin temperature near 32 degrees C; (2) leg-skin temperature near 36 degrees C; (3) leg-skin temperature near 38 degrees C; and (4) epidural anesthesia without leg-warming (leg-skin temperature approximately 34 degrees C). At each designated leg temperature, core hypothermia sufficient to evoke shivering was induced by central venous infusion of cold fluid. Upper-body skin temperature was kept constant throughout. In each volunteer, linear regression was used to calculate the correlation between the shivering thresholds on the 3 non-epidural days and concurrent leg temperatures. The slope of these regression equations thus indicated the extent to which leg-warming increased thermoregulatory tolerance for core hypothermia, and was expressed as a percentage leg-skin and leg-tissue contribution to total thermal afferent input. The skin and tissue temperatures that would have been required to produce the observed shivering threshold during epidural anesthesia, the apparent temperatures, were then interpolated from the regression.
  
  
  RESULTS
  There was a good linear relation between the shivering threshold and leg-skin temperature (r2 = 0.94 +/- 0.06). The contribution of leg-skin temperature to the shivering threshold was 11 +/- 3% of the total thermal input. Apparent leg-skin temperature during epidural anesthesia was 37.8 +/- 0.5 degrees C, which exceeded actual leg-skin temperature by approximately 4 degrees C. The contribution of leg-tissue temperature to the shivering threshold was 19 +/- 7% of the total. Apparent leg-tissue temperature during epidural anesthesia was 37.1 +/- 0.4 degrees C, which exceeded actual leg-skin temperature by approximately 2 degrees C.
  
  
  CONCLUSIONS
  Because leg-skin contributed approximately 11% to the shivering threshold, it is unlikely that the entire skin surface contributes at much less than 20%. These data suggest that the shivering threshold during epidural anesthesia is reduced by a specific mechanism, namely that conduction block significantly increases apparent (as distinguished from actual) leg temperature.
authors.affiliation: Department of Anesthesia, University of California, San Francisco.
authors.forename: T H
authors.initials: TH
authors.lastname: Emerick
authors.forename: M
authors.initials: M
authors.lastname: Ozaki
authors.forename: D I
authors.initials: DI
authors.lastname: Sessler
authors.forename: K
authors.initials: K
authors.lastname: Walters
authors.forename: M
authors.initials: M
authors.lastname: Schroeder
mesh_terms: D000328:Adult; D000767:Anesthesia, Epidural; D001833:Body Temperature Regulation; D005260:Female; D006801:Humans; D007866:Leg; D008991:Monitoring, Physiologic; D012768:Shivering / Q000502:physiology*; D012881:Skin Temperature