Severe Accidental Hypothermia Successfully Treated by Rewarming Strategy Using Continuous Venovenous Hemodiafiltration System

Abstract

A ccidental hypothermia is a serious condition, often with fatal consequences. 1-3 Several active internal rewarming modalities have been described in its management. 4 However, currently, there is no worldwide consensus concerning severity staging and rewarming strategy according to the severity of hypothermia. 2 We report here a case of accidental hypothermia in which continuous venovenous hemodiafiltration (CVVHDF) in combination with a convective air warmer was successfully used as a rewarming technique. We present it with a review of the literature. CASE REPORTA 48-year-old Japanese man was admitted in coma, with severe hemodynamic derangement, bradypnea (SpO 2 85%), anemia (Hb 11.2 g/dL), a marked metabolic acidosis composed of lactic acidosis (pH 7.186, BE -17.8 mmol/L, Lac 121 mg/dL), and severe accidental hypothermia secondary to environmental cold exposure because of consciousness loss after his suicide attempt by cutting the surface skin of both the neck and extremities. On admission, initial examination showed a Glasgow Coma Scale score of 6 and a rectal temperature (core body temperature) of 26.4°C. Twelve-lead electrocardiography (ECG) showed J (Osborn) waves 5 and a prolonged QT interval (Fig. 1).There was no mandatory indication for rewarming by cardiopulmonary bypass because stable circulatory conditions existed. The patient was resuscitated initially with warm intravenous fluids containing dopamine in combination with a convective air warmer. However, this method was slow and the clinical condition was not improved. Therefore, we decided to add a rewarming technique of extracorporeal circulation, continuous venovenous hemodiafiltration (CVVHDF), through cannulation of the femoral vein. The heat transfer was mainly from dialysate warming unit. This dialysate warming unit was well controllable in the fluid temperature in circuit. Moreover, we managed to prevent heat loss from the extracorporeal tubing as follows: we kept the room temperature high and shortened the length of a tube of circuit, and regulated the temperature setting of dialysate warming unit according to body temperature.Consequently, this combination of treatments brought his temperature from 26.8°C to 33.0°C during a 4.5-hour dialysis, with an average rise of 1.37°C/hour (range: 0.2-2.0°C/ hour). His body temperature reached 36.1°C 7.5 hours later, and the J waves on ECG disappeared. The metabolic acidosis was improved (pH 7.354, BE Ϫ3.2 mmol/L, Lac 6.3 mg/dL) 4.0 hours later. Although rhabdomyolysis (CPK 5929 u/L) developed, we did not apparently recognize both the changing of serum potassium and acute myoglobinuric renal failure. The circulatory dynamics was constantly stable in the phase of CVVHDF at a bypass flow rate of 80 to 82 mL/min.The clinical situation clearly improved during the hemodiafiltration session and the patient recovered consciousness after 2.5 hours, with no neurologic sequelae. His medical condition gradually improved without major complications. He was discharged from the emergency and critical care ward on ...

Treatment of severe accidental hypothermia with intermittent hemodialysis

“…16,18 Of the 4 with normal renal function, 2 were treated with intermittent hemodialysis 13,14 and 2 with continuous hemodialysis. 9,17 In contrast, peritoneal dialysis has been more widely used, based on more than 40 published reports. 19 Hemodialysis may be a more effective rewarming method when compared with peritoneal dialysis, as hemodialysis has been successfully used in peritoneal dialysis failures.…”

“…This rewarming rate is consistent with previous reports (Table 1). 9,13,14,[16][17][18] Importantly, there were no further incidents of core temperature after-drop during hemodialysis. Although CPB can achieve more rapid rewarming rates of 7-12°C/h, the relative benefits and harms of such rapid rewarming rates have not been definitively established.…”

“…However, there is little data that demonstrates its superiority over other modalities in patients without circulatory collapse. [8][9][10][11] Moreover, CPB is restricted to specialized centres, is highly invasive and carries with it a high risk of complications. 12 Intermittent hemodialysis is an attractive alternative modality for active core rewarming given its wide availability, rapid rewarming rate and its ability to manage associated metabolic derangements.…”

Active Intravascular Rewarming for Hypothermia Associated with Traumatic Injury: Early Experience with a New Technique

“…Continuous veno-venous rewarming with a 40°C hemodiafiltration (CVVH) machine may produce core rewarming rates of up to 2°C/h in cases of primary (nontrauma) hypothermia but often requires a specially trained nurse or technician for monitoring (12)(13)(14). Continuous arteriovenous rewarming (CAVR) with a 40°C extracorporeal passive countercurrent warmer has been demonstrated specifically in critically injured patients to produce an average core rewarming rate of 2°C/h in the ICU setting.…”

Early Use of Hemodialysis for Active Rewarming in Severe Hypothermia: A Case Report and Review of Literature

“…10 Extracorporeal techniques can be used to directly rewarm blood in patients who do not rewarm with less invasive active internal rewarming techniques or those with completely frozen extremities or severe rhabdomyolysis with hyperkalemia. Several extracorporeal techniques have been used to directly rewarm blood: cardiopulmonary bypass (CPB), 11,12 continuous arteriovenous rewarming (CAVR), 13 continuous venovenous hemofiltration (CVVH), 14 continuous venovenous hemodiafiltration (CVVHDF), 15 and hemodialysis (HD). [16][17][18][19][20] Currently, an active internal rewarming strategy for patients with severe hypothermia has not been established.…”