CLINICALNEPHROLOGYTEACHING CASE

Hemodialysis in Management of Hypothermia

Ali Owda, MD, MRCP, and Sayed Osama, MD
Hypothermia is dened as a core body temperature of less than 35C and is divided further into mild, moderate,
and severe depending on the temperature level. Several active internal rewarming modalities have been described
in the management of moderate-to-severe accidental hypothermia. We report a 73-year-old black man with
underlying end-stage renal failure and ischemic cardiomyopathy who was admitted with severe accidental
hypothermia (core body temperature, 24.9C) secondary to environmental cold exposure. The patient was resusci-
tated initially with warmintravenous uids and peritoneal dialysis with warmuids with an average temperature rise
of 1C. The patient was switched to hemodialysis that brought his temperature from 30.2C to 36.7C during a
3.5-hour dialysis with an average rise of 1.9C/h. Hemodialysis is a rapid and efcient modality of rapid internal
rewarming for moderate-to-severe accidental hypothermia.
2001 by the National Kidney Foundation, Inc.
INDEX WORDS: Hemodialysis (HD); peritoneal dialysis (PD); cardiopulmonary bypass; hypothermia.
A
CCIDENTAL HYPOTHERMIA is an unin-
tentional decline in core body temperature
to less than 35C. Accidental hypothermia is
divided further into mild (32C to 35C), moder-
ate (28C to 32C), and severe (28C).
1
The
annual mortality from accidental hypothermia is
725 lives per year.
2
Management of accidental hypothermia, in
addition to general supportive care, involves
rewarming. Several methods of passive and ac-
tive external rewarming and active internal re-
warming have been described.
1,3,4
Passive re-
warming is the method of choice for mild
hypothermia,
1
whereas active rewarming is em-
ployed for moderate-to-severe hypothermia. Ac-
tive internal rewarming is the most invasive of
the rewarming methods, and different modalities
have been described, including hemodialysis,
5-7
peritoneal dialysis,
4,8,9
cardiopulmonary by-
pass,
4,10
and pleural irrigation.
1
Hemodialysis in the management of acciden-
tal hypothermia rst was described in 1965
5
;
however, there are only a few subsequent reports
of its usage compared with other modalities.
6,7
We describe a case of severe accidental hypother-
mia (core temperature, 24.9C) secondary to
environmental exposure in which active internal
rewarming was initiated by warm intravenous
uid and peritoneal dialysis, then management
was switched to hemodialysis with successful
rapid rewarming.
CASE REPORT
A73-year-old black man was found on December 6, 2000,
unresponsive in the hospital parking lot. The patient was
known to have hypertension, ischemic cardiomyopathy, and
end-stage renal failure secondary to hypertensive nephroscle-
rosis and to be on maintenance hemodialysis through a right
Permcath. The patient had undergone dialysis the day be-
fore. It was not known how long he had been in the hospital
parking lot. The patient was unresponsive, his pupils were
reactive, he was bradycardic with a pulse of 25 beats/min,
and his blood pressure could not be recorded. The patient
was hypothermic with a temperature of 24.9C as measured
by a urinary bladder electrode. The patient had signicant
frostbite of the hands.
Immediately the patient was intubated and covered with a
heated blanket and was started on intravenous warm uid. A
peritoneal catheter was inserted, and irrigation of the perito-
neum was started with warm uid at 40C. After 1 hour into
the rewarming, the patients blood pressure was recorded at
115/59 mmHg; pulse, 70 beats/min; and temperature, 25.2C.
An electrocardiogram showed a sinus rhythm at a rate of 72
beats/min, nonspecic ST changes anterolaterally, and pro-
longed Q-T interval (Q-T
c
, 511 ms). Echocardiography
showed an ejection fraction of 42%, left ventricular enlarge-
ment with hypokinesia, and no evidence of tamponade.
Computed tomography of the brain did not show evidence of
bleed or any other intracranial pathology. Electrolytes were
sodium, 132 mEq/L; potassium, 3.2 mEq/L; bicarbonate, 18
mEq/L; blood urea nitrogen, 54 mg/dL; and creatinine, 4.9
mg/dL. Arterial blood gases on 100% oxygen on the ventila-
tor were pH 7.33; PO
2
, 161 mm Hg; PCO
2
, 46 mm Hg; HCO
3
,
23.4; and 100% saturation.
After 6 hours of resuscitation, the patients temperature
From the Departments of Internal Medicine and Nephrol-
ogy, Hurley Medical Center, Flint, MI.
Received April 23, 2001, and accepted as submitted April
27, 2001.
Address reprint requests to Ali Owda, MD, MRCP, Depart-
ment of Internal Medicine, Hurley Medical Center, Flint, MI
48503. E-mail: aowda1@hurleymc.com
2001 by the National Kidney Foundation, Inc.
1523-6838/01/3802-0032$35.00/0
doi:10.1053/ajkd.2001.26118
American Journal of Kidney Diseases, Vol 38, No 2 (August), 2001: E8 1
increased to only 30.2C, and he remained unresponsive
except for painful stimuli. At this point, the peritoneal
dialysis was discontinued, and hemodialysis was initiated.
The patient received a 3.5-hour dialysis without heparin
anticoagulation with 4 mEq/L potassium and bicarbonate
bath, which was tolerated well throughout without clotting
or hemodynamic compromise. At the end of the dialysis
session, the patients temperature increased to 36.7C (aver-
age, 1.9C/h). The patients further hospital course was
remarkable for the need of debridement of the hands after
the frostbite and the development of gram-positive sepsis.
The patient eventually recovered.
DISCUSSION
Hemodialysis and peritoneal dialysis are well-
established methods of rewarming in accidental
hypothermia. Lee and Ames
5
in 1965 described
the rst use of hemodialysis to treat accidental
hypothermia, and since then there have been
only a few reports of its use.
6,7
Peritoneal dialysis
to manage accidental hypothermia rst was de-
scribed by Lash et al
11
in 1967, and since then
there were more than 40 such reports.
9
In our patient, both methods were used. Ini-
tially, we started rewarming with peritoneal dialy-
sis, and with the slow rewarming the patient was
shifted to hemodialysis. Average temperature re-
warming rate varies (0.6C/h to 4.5C/h), depend-
ing on the rewarming technique. A rewarming
rate of 4.5C/h may be achieved with uid
warmed to 40C.
9
In our patient, the rate of rise
was modest at 1C/h despite the use of warmed
uid at 40C. With hemodialysis, we achieved a
rapid rewarming rate in our patient at a rate of
1.9C/h, which is similar to the rate reported by
Hernandez et al
6
at 2.1C/h.
There are no data comparing hemodialysis
with peritoneal dialysis or with other methods of
rewarming. Van der Maten and Schrijver
12
re-
ported two patients with severe accidental hypo-
thermia in whom peritoneal dialysis failed (no
dwell); both patients were warmed by continu-
ous venovenous hemodiltration. In our patient,
the peritoneal dialysis failure was related to the
slow rewarming rate with this method.
Cardiopulmonary bypass has a rapid rewarm-
ing time, but its disadvantages are that it is not
widely available,
12
it is dependent on physician
experience,
10
it lacks the capability of correcting
the associated electrolyte and acid-base distur-
bances that usually are present in these patients,
and it does not remove drugs and toxins that may
be present in hypothermic victims.
6
Cardiopulmo-
nary bypass is the resuscitation method of choice,
however, in the severely hypothermic victim in
cardiac arrest.
10
In the absence of cardiac arrest,
dialysis is favored over cardiopulmonary by-
pass.
1
Hemodialysis is superior to peritoneal dialysis
with the most important goal of rapid rewarming,
as shown in our patient. Hemodialysis is a rapid
and efcient method of rewarming in moderate-
to-severe accidental hypothermia.
REFERENCES
1. Jolly BT, Ghezzi KT: Accidental hypothermia. Emerg
Med Clin North Am 10:311-327, 1992
2. Hypothermia related deaths. MMWR Morb Mortal
Wkly Rep 47:1037-1040, 1998
3. Weinberg AD: Hypothermia. Ann Emerg Med 22:370-
377, 1993
4. Danzl DF, Pozos RS: Accidental hypothermia. N Engl
J Med 331:1756-1760, 1994
5. Lee MA, Ames AC: Hemodialysis in severe barbitu-
rate poisoning. BMJ 1:1217-1219, 1965
6. Hernandez E, Praga M, Alcazar JM, Morales JM,
Montejo JC, Jimenez MJ, Rodicio JL: Hemodialysis for
treatment of accidental hypothermia. Nephron 63:214-216,
1993
7. Carr ME, Wolfert AI: Rewarming by hemodialysis for
hypothermia: Failure of heparin to prevent DIC. J Emerg
Med 6:277-280, 1988
8. Reuler JB, Parker RA: Peritoneal dialysis in the man-
agement of hypothermia. JAMA240:2289-2290, 1978
9. Mehrotra R: Peritoneal dialysis in adult patients with-
out end-stage renal disease. Adv Perit Dial 16:67-72, 2000
10. Vretenar DF, Urschel JD, Parrott JCW, Unruh HW:
Cardiopulmonary resuscitation for accidental hypothermia.
Ann Thorac Surg 58:895-898, 1994
11. Lash RF, Burdette JA, Ozdil T: Accidental profound
hypothermia and barbiturate intoxication. JAMA 201:123-
124, 1967
12. Van der Maten J, Schrijver G: Severe accidental
hypothermia: Rewarming with CVVHD. Neth J Med 49:160-
163, 1996
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