You Make Me Shiver. DaiWai M. Olson PhD RN University of Texas Southwestern Dallas, TX
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1 You Make Me Shiver DaiWai M. Olson PhD RN University of Texas Southwestern Dallas, TX
2 Outline 1. What is thermogenesis? 2. Why we might care about shivering 3. Measuring shivering 4. Treating Shivering
3 What is Thermogenesis? Metabolic Thermogenesis Mechanical Thermogenesis
4 Hypothalamus The hypothalamus is responsible for temperature regulation Hypothalamus Too Hot start sweating Too Cold start shivering
5
6 Hypothalamus signaling Hypothalamus receives input from: (nucleus of solitary tract, retina, olfactory, limbic, circumventricular, thalamus, reticular formation) and also from thermoreceptors You have thermoreceptors everywhere (especially hands & feet) Hypothalamic AMP-activated protein kinase (AMPK)
7 Metabolic Thermogenesis Put simply heat is a byproduct of metabolism...but... Beyond that... Metabolic thermogenesis takes place in brown adipose tissue. (We all have brown adipose tissue) Thermogenin allows ATP to be dissipated as heat
8 Some exciting scientific controversy that we just don t have time to cover. 1. It may not just be Brown Adipose Tissue....maybe there are others
9 Some exciting scientific controversy that we just don t have time to cover. 2. The signaling pathway may be more complex than we thought
10 But Today mechanical thermogenesis (which is actually a wee bit easier and more intuitive anyway)
11 Shivering occurs through a narrow band of temperature Unfortunately, that narrow band is not well defined
12 What is Shivering Both of these people are shivering One is colder than normal One is hotter than normal
13 Muscle contraction There are TONS of great web resources for muscle contraction. I encourage you to explore them.
14 Muscle contraction - simplified ADP + P HEAT The production of ATP releases heat ATP binding to myosin breaks the actin cross bridge This allows the muscle to tighten (sometimes shorten ) The use of ATP releases heat
15 Why we might care about shivering
16 Heat production Heat Is A Catalyst
17 GABA I.C.P. water temperature Oxygen O 2 Radicals glutamate Glucose Cell Death HgB AMPA Pyruvate perfusion Calcium Lactate
18 Oxygen consumption (aka Energy Demand)
19 Measuring Shivering
20 Measurement Accuracy vs precision Accurate - - Does this correctly measure what you want it to measure? Precision to what degree does measure what you want it to measure? Accuracy vs Precision in SaO2 monitoring
21 Accuracy vs Precision
22 Bedside Shivering Assessment Scale
23 BSAS accuracy & precision Olson DM, Grissom JL, Williamson RA, Bennett SN, Bellows ST, James ML. Interrater reliability of the bedside shivering assessment scale. American journal of critical care 2013;22(1): There was complete agreement in 78% of the paired assessments. Exploring BSAS scores dichotomized to no shivering vs any shivering (κ=0.47). Dichotomizing BSAS scores as little or no shivering vs significant shivering (κ = 0.66). Interpretation is that BSAS has adequate IRR.
24 Bispectral Index and Shivering Shivering during therapeutic hypothermia after cardiac arrest D.B. Seder, T. May, G.L. Fraser, R.R. Riker Resuscitation Volume 82, Issue 2, DOI: /j.resuscitation
25 Treating Shivering The Columbia Anti-Shivering Protocol.
26 Most of the protocols I found (including ours) are escalating. Start with the easy stuff and then progress towards higher pharmacologic interventions.
27 Surface Counter Warming Thermoreceptors Some detect heat - closer to surface of skin Some detect cold - tend to be deeper Not equally distributed: Ear = tons Hand = tons Shin = not so much Back of hand = not so much Experiment: ice cube (ear, hand, back of hand)
28 Poikilothermic Pharmacotherapeutics Neuromuscular Blockades Propofol
29 Questions remain Is Shivering Bad? Is all shivering bad? Is all shivering equally bad? When should we treat shivering? Should we prophylactically treat shivering? What are the best drugs? Combinations? BSAS vs BIS vs?
30 Thank you
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