title: Neither arm nor face warming reduces the shivering threshold in unanesthetized humans.
abstract: OBJECTIVE
  Hand warming and face warming, combined with inhalation of heated air, are reported to suppress shivering. However, hand or face temperature contributes only a few percent to control of shivering. Thus, it seems unlikely that manipulating hand or facial skin temperature alone would be sufficient to permit induction of therapeutic hypothermia. We tested the hypothesis that focal arm (forearm and hand) warming or lower facial warming, combined with inhalation of heated and humidified gas, only minimally reduces the shivering threshold (triggering core temperature).
  
  
  METHODS
  We studied 8 healthy male volunteers (18 to 40 years of age) on 3 days: (1) control (no warming), (2) arm warming with forced air at approximately 43 degrees C, and (3) face warming with 21 L/min of air at approximately 42 degrees C at a relative humidity of 100%. Fluid at approximately 4 degrees C was infused via a central venous catheter to decrease tympanic membrane temperature 1 degrees C/h to 2 degrees C/h; mean skin temperature was maintained at 31 degrees C. A sustained increase in oxygen consumption quantified the shivering threshold.
  
  
  RESULTS
  Shivering thresholds did not differ significantly between the control (36.7+/-0.1 degrees C), arm-warming (36.5+/-0.3 degrees C), or face-warming (36.5+/-0.3 degrees C; analysis of variance, P=0.34) day. The study was powered to have a 95% probability of detecting a difference of 0.5+/-0.5 degrees C (mean+/-SD) between control and either of the 2 treatments at alpha=0.05.
  
  
  CONCLUSIONS
  Focal arm or face warming did not substantially reduce the shivering threshold in unanesthetized volunteers. It thus seems unlikely that these nonpharmacological modalities will substantially facilitate induction of therapeutic hypothermia.
authors.affiliation: Outcomes Research Institute, Department of Anesthesiology, University of Louisville, Louisville, KY, USA. agdoufas@louisville.edu
authors.forename: Anthony G
authors.initials: AG
authors.lastname: Doufas
authors.forename: Anupama
authors.initials: A
authors.lastname: Wadhwa
authors.forename: Chun-Ming
authors.initials: CM
authors.lastname: Lin
authors.forename: Yunus M
authors.initials: YM
authors.lastname: Shah
authors.forename: Keith
authors.initials: K
authors.lastname: Hanni
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Sessler
mesh_terms: D000293:Adolescent; D000328:Adult; D001132:Arm / Q000502:physiology*; D001831:Body Temperature; D015986:Confounding Factors, Epidemiologic; D005145:Face / Q000502:physiology*; D006339:Heart Rate / Q000502:physiology; D006358:Hot Temperature / Q000627:therapeutic use*; D006801:Humans; D007036:Hypothermia, Induced / Q000379:methods*; D008297:Male; D012016:Reference Values; D012129:Respiratory Function Tests; D012684:Sensory Thresholds / Q000502:physiology; D012768:Shivering / Q000502:physiology*; D014851:Wakefulness / Q000502:physiology