title: Accidental hypothermia and active rewarming: the metabolic and inflammatory changes observed above and below 32 degrees C.
abstract: OBJECTIVE
  In accidental hypothermia the underlying physiological mechanisms responsible for poor outcome during rewarming through 32 degrees C remain obscure, although possible associations include changes in acid-base balance, divalent cations, and inflammatory markers. This study investigated the metabolic and inflammatory changes that occur during the rewarming of hypothermic patients.
  
  
  METHODS
  Eight patients, four men and four women, age 45 to 85 years, admitted with core temperatures <35 degrees C were included in the study. Patients were rewarmed with dry warm blankets and fluid replaced by crystalloid at 40 degrees C. Bloods for pH, ionised calcium (Ca(2+)) and magnesium (Mg(2+)), parathyroid hormone (PTH), interleukin 1 (IL1), interleukin 6 (IL6), tissue necrosis factor alpha (TNFalpha), were collected at presentation, during rewarming, and at 24 hours.
  
  
  RESULTS
  Four patients were admitted with mild (32 degrees -35 degrees C) and four with moderate (28 degrees -32 degrees C) hypothermia. Rewarming to 32 degrees C had no significant effect on the presenting acidosis (p=0.1740), although above 32 degrees C pH increased with temperature (p<0.0001). There was a negative correlation between pH and both Ca(2+) (p=0.0005) and Mg(2+) (p=0.0488) below 32 degrees C; above this temperature the relation was significant only for Ca(2+) (p=0.0494). PTH and Ca(2+) correlated positively (p=0.0041) and negatively (p=0.0039) below and above 32 degrees C respectively. There was no relation between IL1 or TNFalpha with Ca(2+) during rewarming, but IL6 and Ca(2+) correlated positively (p=0.0039) and negatively (p=0.0018) when presentation temperature was below and above 32 degrees C respectively.
  
  
  CONCLUSIONS
  During rewarming pH remains unchanged until patient temperature approaches 32 degrees C. Ca(2+) and Mg(2+) decline is associated with the pH increase above 32 degrees C. Poor outcome is associated with presentation temperature (<32 degrees C), non-physiological correlation between IL6-PTH-Ca(2+), and age (>or=84 years).
authors.affiliation: Accident and Emergency Department, The Leicester Royal Infirmary, Leicester, UK.
authors.forename: J J
authors.initials: JJ
authors.lastname: McInerney
authors.forename: A
authors.initials: A
authors.lastname: Breakell
authors.forename: W
authors.initials: W
authors.lastname: Madira
authors.forename: T G
authors.initials: TG
authors.lastname: Davies
authors.forename: P A
authors.initials: PA
authors.lastname: Evans
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002118:Calcium / Q000097:blood; D005260:Female; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007035:Hypothermia / Q000503:physiopathology* / Q000628:therapy*; D008274:Magnesium / Q000097:blood; D008297:Male; D008875:Middle Aged; D017694:Rewarming; D012720:Severity of Illness Index
chemical_list: D008274:Magnesium; D002118:Calcium