Predictores de mortalidad precoz en pacientes con trauma complejo hemorrágico / Early mortality predictors in patients with complex hemorrhagic trauma

RESUMEN Fundamento: El trauma complejo es un problema de salud a nivel mundial y cuando es de tipo hemorrágico la mortalidad es superior a los otros tipos de traumas complejos. Objetivo: Determinar las variables predictoras de mortalidad precoz en pacientes hospitalizados con trauma complejo hemorrágico en una institución hospitalaria del segundo nivel de atención en Cuba. Metodología: Se realizó un estudio transversal en el Hospital General Provincial Camilo Cienfuegos de Sancti Spíritus, durante 6 años. Se incluyeron 207 pacientes. Las variables se agruparon en sociodemográficas, enfermedades crónicas asociadas, mecanismo lesional, tipo de trauma, localización topográfica, tiempo entre admisión hospitalaria, diagnóstico y tratamiento, complicaciones precoces, tratamiento médico y quirúrgico, y mortalidad precoz. Se elaboró un árbol de decisión mediante el método Chaid exhaustivo, la variable dependiente fue la mortalidad por trauma complejo hemorrágico. Resultados: Predominaron los pacientes del sexo masculino (85 %), con 60 años y menos (83 %), con trauma contuso (57.5 %) y politraumatizados (42.5 %). Predominaron también los que presentaron acidosis metabólica (66.7 %), coagulopatía aguda (44.4 %), hipotermia (41.5 %). El 30 % de los pacientes falleció precozmente. El árbol de decisión tuvo una sensibilidad de 82.3 %, una especificidad de 97.2 % y un porcentaje global de pronóstico correcto del 92.8 %. Se identificaron 4 variables predictores de mortalidad: hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante. Conclusiones: La probabilidad más alta de fallecer precozmente durante un trauma complejo hemorrágico se da entre pacientes con hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante.

ABSTRACT Background: Complex trauma is a worldwide health problem and when hemorrhagic, mortality is higher than other types of complex trauma. Objective: To determine predictive variables of early mortality in hospitalized patients with complex hemorrhagic trauma in a second care level hospital in Cuba. Methodology: A cross-sectional study was conducted at Camilo Cienfuegos Provincial General Hospital in Sancti Spíritus, for 6 years. 207 patients were included. The variables were grouped into sociodemographic, associated chronic diseases, injury mechanism, type of trauma, topographic location, time between hospital admission, diagnosis and treatment, early complications, medical and surgical treatment, and early mortality. A decision tree was developed using the exhaustive Chaid method, the dependent variable was mortality due to complex hemorrhagic trauma. Results: Male patients (85 %), 60 years and younger (83 %), with blunt trauma (57.5 %) and polytraumatized patients (42.5 %) predominated. Those who presented metabolic acidosis (66.7 %), acute coagulopathy (44.4 %), and hypothermia (41.5 %) also predominated. 30 % of patients died early. The decision tree had a sensitivity of 82.3 %, a specificity of 97.2 % and an overall percentage of correct forecast of 92.8 %. Four variables that predicted mortality were identified: hypothermia, metabolic acidosis, acute coagulopathy, and penetrating trauma. Conclusions: The highest probability of early dying during a complex hemorrhagic trauma occurs among patients with hypothermia, metabolic acidosis, acute coagulopathy and penetrating trauma.

Survival at 30 days in elderly patients with hip fracture surgery who were exposed to hypothermia: Survival study.

ABSTRACT: The effect of hypothermia as a mortality risk factor at 30 days in the elderly who had hip fracture (HF) surgery is still controversial because it may be due to a set of poorly identified factors. In this study, we aim to determine if exposure to intra and immediate postoperative hypothermia increases the incidence of mortality at 30 days in elderly patients who had HF surgery.Survival study in the elderly who had HF surgery with and without exposure to hypothermia. Sociodemographic, anesthetic and surgical factors were collected. The temperature of the rectum was measured at the end of the surgery and in the recovery room. The effect of hypothermia was analyzed by the incidence of mortality at 30 days. Other results were considered, such as, surgical site infection (SSI), blood transfusions, and influence of implants used in the 30-day mortality.Three hundred eighty five subjects were eligible, to include 300. Inadvertent hypothermia was 12%, the 30-day overall mortality was 9% and in subjects with hypothermia it was 25% (P = .002). Subjects with hypothermia had a higher risk of SSI (relative risk 4.2, 95% confidence interval 1.3-13.6, P = .03) and receive more transfusions (relative risk 3.6, 95% confidence interval 2.0-6.5, P < .001).Elderly subjects with HF exposed to hypothermia who undergo hip hemiarthroplasty and who receive 2 or more blood transfusions during their treatment, are at greater risk of dying after 30 days of the surgery. Hypothermia, as a possible causative factor of mortality, should continue to be studied.

Association of intraoperative hypothermia with oncologic outcomes following radical cystectomy.

INTRODUCTION: Intraoperative hypothermia (IOH) has been suggested to adversely impact outcomes following surgery. The objective of this study was to evaluate the association between IOH and survival following radical cystectomy (RC). METHODS: Patients who underwent RC for bladder cancer from 2003 to 2018 were identified in our cystectomy registry. Intraoperative temperatures were extracted from the anesthesia record. IOH was defined as a median intraoperative temperature <36°C, and severe IOH as ≤ 35°C. Time under 36°C was assessed as a continuous variable. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were estimated using the Kaplan-Meier method. Associations between IOH and outcomes were assessed with multivariable Cox proportional hazards models. RESULTS: A total of 852 patients were identified, among whom 274 (32%) had IOH. Median follow up among survivors was 4.9 years (IQR 2.4-8.7), during which time 483 patients died, including 343 from bladder cancer. Two-year survival was not significantly different between patients with and without IOH (CSS: 74% vs. 71%, P= 0.31; OS: 68% vs. 67%, P= 0.13). Following multivariable adjustment, neither IOH nor time under 36°C was significantly associated with survival. A total of 37 patients (4.3%) had severe IOH. These patients were observed to have significantly lower 2-year OS (56% vs. 68%, P= 0.005); however, this association did not remain statistically significant after multivariable adjustment (P= 0.92). CONCLUSION: IOH was not independently associated with survival following RC. These data do not support IOH as a prognostic factor for cancer outcomes among patients undergoing RC.

Hypothermia Deaths in Van Province, Turkey

ABSTRACT Objective: To evaluate autopsy findings in hypothermia-related deaths in Van Province, Turkey, a city near the Turkey-Iran border. Methods: Autopsy reports on 43 hypothermia fatalities were retrospectively reviewed. Data regarding age, gender, nationality of the cases, seasonality of the deaths, crime scene findings, autopsy findings, manner of deaths, risk factors for hypothermia, other traumatic lesions, and toxicology were obtained from autopsy records and scene investigation records. Results: There were 36 males and 7 females. The mean age was 20.5 years. More than half of the cases died or were found dead in the spring months. All but one of the cases was found dead outdoors. There were common red-coloured livor mortis in 33 cases (76.7%), antemortem traumas in 16 cases (37.2%), cold erythema in 26 cases (60.5%), myxedema in 1 case, bloody discolouration in the synovial fluid in 11 (84.6%) cases, and Wischnewski spots in 32 cases (74.4%). Conclusion: The study showed that illegal refugees are an important social problem in Turkey. Hypothermia should be considered as a cause of death for refugees when they are found, especially in the cold provinces. In the diagnosis of hypothermia, bloody discolouration of the synovial fluid is confirmed to be a valuable finding. Wischnewski spots remain valuable for positive identification.

The Impact of Accidental Hypothermia on Mortality in Trauma Patients Overall and Patients with Traumatic Brain Injury Specifically: A Systematic Review and Meta-Analysis.

BACKGROUND: Accidental hypothermia is a known predictor for worse outcomes in trauma patients, but has not been comprehensively assessed in a meta-analysis so far. The aim of this systematic review and meta-analysis was to investigate the impact of accidental hypothermia on mortality in trauma patients overall and patients with traumatic brain injury (TBI) specifically. METHODS: This is a systematic review and meta-analysis using the Ovid Medline/PubMed database. Scientific articles reporting accidental hypothermia and its impact on outcomes in trauma patients were included in qualitative synthesis. Studies that compared the effect of hypothermia vs. normothermia at hospital admission on in-hospital mortality were included in two meta-analyses on (1) trauma patients overall and (2) patients with TBI specifically. Meta-analysis was performed using a Mantel-Haenszel random-effects model. RESULTS: Literature search revealed 264 articles. Of these, 14 studies published 1987-2018 were included in the qualitative synthesis. Seven studies qualified for meta-analysis on trauma patients overall and three studies for meta-analysis on patients with TBI specifically. Accidental hypothermia at admission was associated with significantly higher mortality both in trauma patients overall (OR 5.18 [95% CI 2.61-10.28]) and patients with TBI specifically (OR 2.38 [95% CI 1.53-3.69]). CONCLUSIONS: In the current meta-analysis, accidental hypothermia was strongly associated with higher in-hospital mortality both in trauma patients overall and patients with TBI specifically. These findings underscore the importance of measures to avoid accidental hypothermia in the prehospital care of trauma patients.

Postmortem diagnosis of ketoacidosis: Levels of beta-hydroxybutyrate, acetone and isopropanol in different causes of death.

Data from 496 autopsy cases with positive beta hydroxybutyrate (BHB), acetone or isopropanol in blood were investigated. The cases were divided into different groups according to cause of death. Cases with cause of death due to diabetic ketoacidosis (DKA, n=54) had the highest levels of BHB (median 1085mg/L) and acetone (median 330mg/L). Cases with cause of death due to alcoholic ketoacidosis (AKA, n=57) had high levels of BHB (median 500mg/L) and acetone (median 110mg/L). Cases with cause of death due to hypothermia (n=12) had similar BHB and acetone levels as the AKA group (median BHB 520mg/L and acetone 80mg/L). Cases with cause of death due to isopropanol intoxication (n=17) had high levels of isopropanol (median 430mg/L) and acetone (330mg/L), but undetected or low levels of BHB. Cases with cause of death due to other than the above mentioned (n=349) had median BHB levels of 100mg/L and median acetone levels of 20mg/L. BHB analysis is crucial for the diagnosis of postmortem ketoacidosis, since it is the main marker of ketoacidosis and helps distinguish between different causes of death. Acetone levels correlate with BHB levels in endogenous ketoacidosis, so acetone can be used as an initial screening marker to identify cases where BHB analysis should be performed, but positive acetone threshold should be maximum 20mg/L. Positive BHB is proof of endogenous ketoacidosis, whereas negative BHB indicates isopropanol intoxication or postmortem acetone/isopropanol formation by microorganisms in cases of decomposition. There is no correlation between BHB and the postmortem interval, and no sign of postmortem formation, so BHB analysis is useful even in cases of severe decomposition.

Molecular mechanisms of Wischnewski spot development on gastric mucosa in fatal hypothermia: an experimental study in rats.

Numerous dark-brown-coloured small spots called "Wischnewski spots" are often observed in the gastric mucosa in the patients dying of hypothermia, but the molecular mechanisms through which they develop remain unclear. We hypothesised that hypothermia may activate the secretion of gastric acid and pepsin, leading to the development of the spots. To investigate this, we performed experiments using organotypic rat gastric tissue slices cultured at 37 °C (control) or 32 °C (cold). Cold loading for 6 h lowered the extracellular pH in the culture medium. The mRNA expression of gastrin, which regulates gastric acid secretion, increased after cold loading for 3 h. Cold loading increased the expression of gastric H+,K+-ATPase pump protein in the apical canalicular membrane and resulted in dynamic morphological changes in parietal cells. Cold loading resulted in an increased abundance of pepsin C protein and an elevated mRNA expression of its precursor progastricsin. Collectively, our findings clarified that cold stress induces acidification by activating gastric H+,K+-ATPase pumps and promoting pepsin C release through inducing progastricsin expression on the gastric mucosa, leading to tiny haemorrhages or erosions of the gastric mucosa that manifest as Wischnewski spots in fatal hypothermia.

'Cold and lonely': emergency presentations of patients with hypothermia to a large Australian health network.

BACKGROUND: Extreme heat is a public health priority in Australia with the health effects of cold poorly studied. A record-breaking cold winter prompted an institutional investigation into the epidemiology and outcomes of hypothermic presentations. AIMS: To describe the clinical and epidemiological characteristics of hypothermic emergency presentations including patient outcomes as well as gaps in practice. METHODS: This was a retrospective cohort observational study of hypothermic emergency presentations between 7 July 2009 and 1 September 2016 with a temperature of ≤35°C. Independent predictors for inpatient mortality and characteristics of exposure versus non-exposure presentations were evaluated. RESULTS: There were 217 patients with 226 presentations comprising male gender in 54%, median age 76.5 years (interquartile range (IQR) 53-88) and median initial temperature 33.3°C (IQR 31.2-34.3°C). Non-exposure presentations being found indoors, accounted for 78% overall, with elderly persons ≥65 years (P = 0.002) and multimorbidity (Charlson comorbidity index ≥4, P = 0.013) overrepresented in this subgroup. Among the non-exposure cohort, 55% were pensioners and 42% lived alone. Inpatient mortality was 11% overall and significantly higher in non-exposure versus exposure cohorts (16 vs 2%, P = 0.01). Independent predictors of inpatient mortality included heart failure (P = 0.04), metastatic malignancy (P < 0.01), chronic kidney disease (P < 0.05) and sepsis (P < 0.01). In contrast, exposure-related presentations were characterised by younger patients with intoxication due to alcohol and/or illicit drugs and psychiatric comorbidity. CONCLUSIONS: Hypothermia is a marker of clinical and socioeconomic vulnerability. The dominant presentation of the elderly patient with multimorbidity, and few social supports being found indoors, raises broader questions around the social determinants of health.

Association Between Postoperative Body Temperature and All-Cause Mortality After Off-Pump Coronary Artery Bypass Graft Surgery: A Retrospective Observational Study.

BACKGROUND: Inadvertent perioperative hypothermia is common in patients undergoing off-pump coronary artery bypass grafting (OPCAB). We investigated the association between early postoperative body temperature and all-cause mortality in patients undergoing OPCAB. METHODS: We reviewed the electronic medical records of 1714 patients who underwent OPCAB (median duration of follow-up, 47 months). Patients were divided into 4 groups based on body temperature at the time of intensive care unit admission after surgery (moderate-to-severe hypothermia, <35.5°C; mild hypothermia, 35.5°C-36.5°C; normothermia, 36.5°C-37.5°C; and hyperthermia, ≥37.5°C). Cox proportional hazards models were used to assess the association between body temperature and all-cause mortality. The association between early postoperative changes in body temperature and all-cause mortality was also assessed by dividing the patients into 4 categories according to the body temperature measured at postoperative intensive care unit admission and the average body temperature during the first 3 postoperative days. RESULTS: Compared to the normothermia group, the adjusted hazard ratios of all-cause mortality were 2.030 (95% confidence interval, 1.407-2.930) in the moderate-to-severe hypothermia group and 1.445 (95% confidence interval, 1.113-1.874) in the mild hypothermia group. Patients who were hypothermic at postoperative intensive care unit admission but attained normothermia thereafter were at a lower risk of all-cause mortality compared to patients who did not regain normothermia (adjusted hazard ratio, 0.631; 95% confidence interval, 0.453-0.878), while they were still at a higher risk of all-cause mortality than those who were consistently normothermic (adjusted hazard ratio, 1.435; 95% confidence interval, 1.090-1.890). CONCLUSIONS: Even mild early postoperative hypothermia was associated with all-cause mortality after OPCAB. Patients who regained normothermia postoperatively were at lower risk of all-cause mortality compared to those who did not.

The impact of hypothermia on outcomes in massively transfused patients.

BACKGROUND: Hypothermia is associated with poor outcomes after injury. The relationship between hypothermia during contemporary large volume resuscitation and blood product consumption is unknown. We evaluated this association, and the predictive value of hypothermia on mortality. METHODS: Patients predicted to receive massive transfusion at 12 level 1 trauma centers were randomized in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial and were grouped into those who were hypothermic (<36°C) or normothermic (36-38.5°C) within the first 6 hours of emergency department arrival. The impact of hypothermia or normothermia on the volume of blood product required during the first 24 hours was determined via negative binomial regression, adjusting for treatment arm, injury severity score, mechanism, demographics, pre-emergency department fluid volume, blood administered before becoming hypothermic, pulse and systolic blood pressure on arrival, and the time exposed to hypothermic or normothermic temperatures. RESULTS: Of 680 patients, 590 had a temperature measured during the first 6 hours in hospital, and 399 experienced hypothermia. The mean number of red blood cell (RBC) units given to all patients in the first 24 hours of admission was 8.8 (95% confidence interval [CI], 7.9-9.6). In multivariable analysis, every 1°C decrease in temperature below 36.0°C was associated with a 10% increase (incidence rate ratio, 0.90; 95% CI, 0.89-0.92; p < 0.00) in consumption of RBCs during the first 24 hours of admission. There was no association between RBC administration and a temperature above 36°C. Hypothermia on arrival was an independent predictor of mortality, with an adjusted odds ratio of 2.7 (95% CI, 1.7-4.5; p < 0.00) for 24-hour mortality and 1.8 (95% CI, 1.3-2.4; p < 0.00) for 30-day mortality. CONCLUSION: Hypothermia is associated with increase in blood product consumption and mortality. These findings support the maintenance of normothermia in trauma patients and suggest that further investigation on the impact of cooling or rewarming during massive transfusion is warranted. LEVEL OF EVIDENCE: Prognostic, level III.

Accidental hypothermia as an independent risk factor of poor neurological outcome in older multiply injured patients with severe traumatic brain injury: a matched pair analysis.

PURPOSE: Patients with multiple injuries are particularly susceptible to accidental hypothermia which is correlated with an increased risk of post-traumatic complications and mortality; however, its impact on neurological outcome in cases where there is concomitant traumatic brain injury is underexplored. METHODS: We analyzed severely injured patients (ISS ≥ 16) including a moderate-to-severe traumatic brain injury (AISHead ≥ 3). The primary endpoint was objective neurological recovery, expressed as Glasgow Outcome Scale (GOS) score at time of discharge. Secondary endpoints were mortality, systemic inflammatory response syndrome (SIRS), sepsis, acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS). Statistical analysis included logistic regression (odds ratio). The significance level in all analyses was p = 0.05. RESULTS: We analyzed 278 patients (M age = 43 years, SD 19; M ISS = 32.8, SD 10.7). Mortality was 17% (n = 14). 102 patients (37%) were hypothermic on admission. Hypothermic patients were more severely injured (ISS 35.6 ± 11.1 vs. 31.2 ± 10.1, p = 0.001; APACHE II 18.1 ± 7.4 vs. 16.2 ± 7.3, p = 0.045) and had a higher transfusion requirement. Mortality rate in hypothermic patients was increased (23.5 vs. 13.1%, p = 0.03); however, hypothermia was not an independent predictor of mortality. Median GOS at discharge was 3 (IQR 3); in 47% of patients the outcome was favorable (GOS 4 or 5) and 36% it was poor (GOS 2 or 3). There were no differences in post-traumatic complications. Analysis of 73 matched pairs of hypothermic and normothermic patients could not prove hypothermia as an independent predictor of poor neurological outcome (OR 1.7, 95% CI 0.8-3.6, p = 0.1) in the total population. However, older patients (> 41 years) had a 4.2-times higher risk (95% CI 1.4-12.7; p = 0.01) of poor neurological outcome, if they were hypothermic on admission. CONCLUSIONS: Accidental hypothermia seems to have a negative impact on neurological recovery in older patients with multiple injuries including traumatic brain injury which outweighs potential benefits.

The beneficial effect of air cleanliness with ISO 14644-1 class 7 for surgical intervention in a neonatal intensive care unit: A 10-year experience.

Whether critically ill neonates needing a surgical intervention should be transferred to an operating room (OR) or receive the intervention in a neonatal intensive care unit (NICU) is controversial. In this study, we report our experience in performing surgical procedures in a NICU including air cleanliness.This was a retrospective study performed at a metropolitan hospital. The charts of all neonates undergoing surgical procedures in the NICU and OR were retrospectively reviewed from January 2007 to June 2017. Data on baseline characteristics, procedure and duration of surgery, ventilator use, hypothermia, instrument dislocations, surgery-related infections and complications, and outcomes were analyzed.Ninety-two neonates were enrolled in this study, including 44 in the NICU group and 48 in the OR group. The air cleanliness was International Organization for Standardization (ISO) 14644-1 class 7 in the NICU and class 5-6 in the OR. The NICU group had a younger gestational age and lower birth body weight than the OR group. The OR group had a higher incidence of hypothermia than in the NICU group (56.3% vs 9.1%, P < .001). However, there were no significant differences in surgical site related infections or mortality between the 2 groups.This study suggests that performing surgical procedures in a NICU with air cleanliness class 7 is as safe as in an OR, as least in part, when performing patent ductus arteriosus ligation and exploratory laparotomy.

Hypothermia at neonatal intensive care unit admission was not associated with respiratory disease or death in very preterm infants.

AIM: This study investigated the association between hypothermia and respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD) or death in very preterm infants admitted to a Danish neonatal intensive care unit (NICU). METHODS: We studied 675 infants born at Aalborg University Hospital before 32 weeks and admitted to the NICU from April 1997 to December 2011. Hypothermia was defined as a core temperature of <36.5°C on admission. The primary outcome was severe RDS or death within the first three days of life, and the secondary outcome was BPD or death before 36 postmenstrual weeks. The multivariable logistic regression was adjusted for early-onset infection, gestational age, Apgar score, sex, treatment year and birth weight. RESULTS: Infants with hypothermia had a twofold increase (OR) in the odds for RDS or death (2.03), but the adjusted OR was not statistically significant (1.36). They also demonstrated a twofold increase (OR) in the odds for BPD or death (2.28), but again the adjusted OR was not statistically significant (1.03). CONCLUSION: After adjusting for confounders, we found that the association between hypothermia on admission to the NICU and RDS or death, or BPD or death was statistically insignificant.

Expression of Hsp27 and Hsp70 and vacuolization in the pituitary glands in cases of fatal hypothermia.

Hypothermia causes systemic cellular stress. The pituitary gland is an endocrine gland and plays an important role in thermoregulation. When the core body temperature drops, the pituitary gland is activated by stimulation of hypothalamic hormones. In this study, we investigated morphological alterations of the pituitary gland in cases of fatal hypothermia. Several morphological alterations of the anterior lobe of the pituitary gland, such as hemorrhage, vacuolization, and hyperemia, have been previously described in fatal hypothermia. However, the diagnostic value of these findings is controversial. We compared 11 cases of fatal hypothermia with 10 cases lacking antemortem hypothermic influences. In the presence of thermal cellular stress, the expression of heat shock proteins increases to protect cellular structures. Therefore, we immunohistochemically analyzed Hsp27 and Hsp70. Hsp27 expression was detected in 27.3% of the cases of fatal hypothermia and in 10.0% of the control cases, whereas Hsp70 expression was not detected in any case. Additionally, Sudan staining was performed to quantify fatty degeneration. A positive reaction was found in 45.5% of the study group and in 10.0% of the control group. This indicates that fatty degeneration might be a valuable marker when other macroscopic signs of hypothermia are absent.

The Significance of Hypothermia in Abdominal Aortic Aneurysm Repair.

BACKGROUND: The aim of this study was to review the literature on the association between hypothermia and outcomes in open and endovascular abdominal aortic aneurysm (AAA) repair. The secondary aim was to determine whether there is a difference in body temperature in patients undergoing either transperitoneal (TP), retroperitoneal (RP), or endovascular surgical repair of the abdominal aorta (EVAR). METHODS: MEDLINE, Web of Science, and Trip searched for all studies on temperature in the context of aortic surgery or endovascular aortic interventions. To be included in the review, the papers had to be related to intraoperative or postoperative hypothermia and/or normothermia, with regards to either open or endovascular repair of the abdominal aorta. Thoracic or thoracoabdominal aortic repairs were not included for review. RESULTS: Eight studies involving 765 patients were eligible. Of these, 6 studies looked at open elective AAA repair involving 605 patients. Only 2 studies investigated emergency AAA repair and consisted of 160 patients where only 35 of those patients underwent emergency EVAR. Normothermic patients had a shorter length of stay in the intensive care unit (P = 0.0008), while hypothermia was independently associated with higher rates of organ dysfunction, in-hospital mortality, and prolonged hospital length of stay. In ruptured AAAs, the lowest average intraoperative temperature was recorded in open repair compared with EVAR (P = 0.02). There was no statistically significant difference in postoperative temperature between patients undergoing elective RP repair and those having TP surgery. CONCLUSIONS: The studies identified in this review have shown that hypothermia has numerous deleterious effects on outcomes in AAA repair - whether or not these adverse outcomes are those such as higher rates of organ dysfunction, mortality or prolonged hospital length of stay, can only be done at the single paper level and not at a literature review level, due to multiple confounding variables. Despite these limitations, the benefits of this review are numerous. This article highlights the importance of core body temperature and outcomes of AAA repair. Furthermore, it brings forth the need to standardize the method of core body temperature measurement and method of rewarming. Given the body of evidence so far, these standardized data collection points will be important for national vascular quality improvement initiatives. Only through rigorous analysis of standardized dataset can firm recommendation regarding peri- and postoperative temperature management be made.

Outcome After Rewarming From Accidental Hypothermia by Use of Extracorporeal Circulation.

BACKGROUND: Accidental hypothermia with arrested circulation remains a condition associated with high mortality. In our institution, extracorporeal circulation (ECC) rewarming has been the cornerstone in treating such patients since 1987. We here explore characteristics and outcomes of this treatment, to identify significant merits and challenges from 3 decades of experience in ECC rewarming. METHODS: Sixty-nine patients rewarmed by ECC during the period from December 1987 to December 2015 were analyzed. One patient was excluded from the analyses because of combined traumatic cerebral injury. The analysis was focused on patient characteristics, treatment procedures, and outcomes were focused. Survivors were evaluated according to the cerebral performance categories scale. Simple statistics with nonparametric tests and χ2 tests were used. Median value and range are reported. RESULTS: Median age was 30 years (minimum 1.5, maximum 76), and the cause of accidental hypothermia was cold exposure (27.9%), avalanche (5.9%), and immersion/submersion accidents (66.2%). Eighteen patients survived (26.5%). The survival rate did not improve during the years. Survivors had lower serum potassium (p = 0.002), higher pH (p = 0.03), lower core temperature (p = 0.02), and shorter cardiopulmonary resuscitation time (p = 0.001), but ranges were wide. Although suspected primary hypoxia and hypothermia were associated with lower survival, we observed a 10.5% survival of these victims. Sixteen survivors had good outcome (cerebral performance category 1 or 2), whereas 2 patients with suspected primary hypoxia survived with severe cerebral disability (cerebral performance category 3). CONCLUSIONS: Despite extended experience with ECC rewarming, improved handling strategies, and intensive care, no overall improvement in survival was observed. Good outcome was observed even among patients with a dismal prognosis.

Epidemiology and outcomes of children with accidental hypothermia: A propensity-matched study.

BACKGROUND: The purpose of this study was to explore the epidemiology and outcomes of hospitalized children with a diagnosis of accidental hypothermia. METHODS: The 2012 Kids' Inpatient Database, detailing discharge diagnoses in children admitted to US hospitals, was analyzed using International Classification of Diseases, Ninth Revision, Clinical Modification codes to filter out relevant patients. Children ages 1 month to 17 years were included in the analysis. Demographic and outcome variables in the hypothermia group were compared with the rest of the patients. In a separate analysis, children with hypothermia were matched 1:1 using a correlative propensity score using sex, age, hospital region, income quartiles, race, ventilation status, coagulopathy, drowning, and All Patient Refined Diagnosis Related Groups severity score and their outcomes were compared with controls. The sample data were weighted to get a national estimate. RESULTS: Accidental hypothermia was present in 1,028 cases out of 1,915,435 discharges. Children with hypothermia were more likely to be males (54.7% vs. 50.9%; p < 0.05) and infants (32.6% vs. 17.5%); they were less likely to be teens (30% vs. 37.8%). Children with hypothermia were more likely to be admitted in the Southern region (48.3% vs. 38.4%; p < 0.05) and have a higher mortality rate compared to all other discharges (8.5% vs. 0.3%; p < 0.05) or when compared with the matched controls (8.9% vs. 4.4%). CONCLUSIONS: The diagnosis of accidental hypothermia significantly increased mortality in hospitalized children. Interestingly, accidental hypothermia was more common in Southern states compared to the other areas of the United States. LEVEL OF EVIDENCE: Prognostic/epidemiological study, level III.

Morbidity and mortality associated with rewarming hypothermic very low birth weight infants.

OBJECTIVES: In very low birthweight (VLBW) infants, hypothermia is associated with poor outcomes. The goal of this study is to assess the relationship between the rate of rewarming these babies and their outcomes. METHODS: This is a retrospective cohort study of 98 inborn VLBW infants who were hypothermic (<36°C rectally) upon admission to the NICU. A logistic regression model was used to examine the relationship between the rates of rewarming and time to achieve euthermia and the following outcomes: death, intraventricular hemorrhage, severe intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis and retinopathy of prematurity. RESULTS: Prolonged rewarming time was associate with increased odds of mortality (OR 1.273 95% CI 1.032-1.571). No associations between rewarming rates and any of the outcomes were seen. Once birthweight was included in a multiple logistic regression model, the association between mortality and rewarming time was no longer significant. Outcomes that were not associated with either rate or time of rewarming (even in a univariate model) were: bronchopulmonary dysplasia, intraventricular hemorrhage, severe intraventricular hemorrhage, necrotizing enterocolitis and retinopathy of prematurity. CONCLUSION: In moderately hypothermic VLBW infants, after accounting for birthweight, no association between rewarming and outcome is seen.

Hypothermia is an independent predictor of short and intermediate term mortality in acute systolic heart failure: Insights from the ESCAPE trial.

INTRODUCTION: Admission hypothermia is associated with increased mortality in patients hospitalized with sepsis, trauma or stroke. We hypothesized that hypothermia on admission in patients with acute systolic heart failure (HF) would be associated with worse survival. METHODS: Using ESCAPE trial data, we compared patients hospitalized with acute systolic HF with admission temperature ≤35.5°C or >35.5°C. The study endpoints were 30-day and 6-month all-cause mortality. RESULTS: Among the 398 patients (mean age 56years, 74% men) who had body temperature recorded on hospital admission, 23 had a temperature ≤35.5°C (hypothermia) and 375 patients had a temperature >35.5°C. By univariate comparison, hypothermic patients had a higher blood urea nitrogen (BUN) level (46.6versus 34.6mg/dL, P=0.04) and creatinine level (1.85 versus 1.49mg/dL, P=0.035) and higher frequency of malignancy (26.1% versus 6.1%, P=0.001). There was a significant correlation between admission temperature and body mass index (r=0.201, P<0.0001). Patients with temperature≤35.5°C had a higher 30-day (17.4% versus 4.3%, univariate OR 4.724, 95% CI 1.439-15.509, P=0.01) and 6-month (43.5% versus 18.1%, univariate OR 3.473, 95% CI 1.462-8.25, P=0.005) all-cause mortality. Cox proportional hazard analysis revealed that admission temperature ≤35.5°C is an independent predictor of mortality (hazard ratio 2.222, 95% CI 1.117-4.420, P=0.023). Kaplan-Meier analysis comparing survival in patients with admission temperature ≤35.5°C or >35.5°C showed a significant inter-group difference in survival (log-rank P value=0.001). CONCLUSION: Admission body temperature ≤35.5°C is an independent predictor of short and intermediate term mortality in patients hospitalized with acute systolic HF.

A recommended early goal-directed management guideline for the prevention of hypothermia-related transfusion, morbidity, and mortality in severely injured trauma patients.

Hypothermia is present in up to two-thirds of patients with severe injury, although it is often disregarded during the initial resuscitation. Studies have revealed that hypothermia is associated with mortality in a large percentage of trauma cases when the patient's temperature is below 32 °C. Risk factors include the severity of injury, wet clothing, low transport unit temperature, use of anesthesia, and prolonged surgery. Fortunately, associated coagulation disorders have been shown to completely resolve with aggressive warming. Selected passive and active warming techniques can be applied in damage control resuscitation. While treatment guidelines exist for acidosis and bleeding, there is no evidence-based approach to managing hypothermia in trauma patients. We synthesized a goal-directed algorithm for warming the severely injured patient that can be directly incorporated into current Advanced Trauma Life Support guidelines. This involves the early use of warming blankets and removal of wet clothing in the prehospital phase followed by aggressive rewarming on arrival at the hospital if the patient's injuries require damage control therapy. Future research in hypothermia management should concentrate on applying this treatment algorithm and should evaluate its influence on patient outcomes. This treatment strategy may help to reduce blood loss and improve morbidity and mortality in this population of patients.