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Hypothermia is a medical condition in which the victim's core body temperature has dropped to significantly below normal and normal metabolism begins to be impaired. This begins to occur when the core temperature drops below 35 degrees Celsius (95 degrees Fahrenheit). If body temperature falls below 32 °C (90 °F), the condition can become critical and eventually fatal. Body temperatures below 27 °C (80 °F) are almost uniformly fatal, though body temperatures as low as 14 °C (57.5 °F) have been known to survive. The opposite condition, where temperature is too high, is hyperthermia. more...

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For unknown reasons, people who fall critically unconscious (and arguably die, though there are some who argue that any reversible condition is not, by definition, death) in very cold water can, in rare cases, be resuscitated, even though they would be expected to have died of drowning and/or hypothermia. See Mammalian diving reflex.


There are three types of hypothermia, acute, subacute, and chronic.

  • Acute hypothermia is the most dangerous; the body temperature drops very swiftly, often in a matter of seconds or minutes, such as when a victim falls through an ice-covered lake.
  • Subacute hypothermia occurs on a scale of hours, most commonly by remaining in a cold environment for an extended period of time.
  • Chronic hypothermia is typically caused by an underlying disease.


  • Amnesia
  • Ataxia
  • Cold skin, even in torso
  • Confusion, progressing to delirium
  • Diuresis
  • Dysarthria
  • Gray complexion (pallor)
  • Hypokinesia
  • Increased muscle tone
  • Low blood pressure (hypotension)
  • Peripheral cyanosis
  • Rapid breathing (tachypnea) and heart rate (tachycardia), slowing and weakening as temperature decreases
  • Shivering
  • Tremor
  • Uncontrollable bleeding due to reduced coagulation enzyme activity
  • Weakness


Treatment for hypothermia involves raising the core body temperature of the victim.

The first aid response to someone experiencing hypothermia, however, must be made with caution.

  • Do not rub or massage the casualty
  • Do not give alcohol
  • Do not treat any frostbite
  • Do not allow the body to become vertical

Any of these actions will divert blood from the critical internal organs and will worsen the situation.

What you should do:

  • Call the emergency services
  • Get the patient to shelter
  • If possible, put the patient in a bath with medium-temperature water, with the clothes on
  • Place hot water bottles (wrapped in a cotton sock) in the patient's armpits and between their legs
  • Give food and warm drinks
  • Monitor the patient and be prepared to give Cardio-pulmonary resuscitation.
  • Remove wet clothing if and only if a dry change is available

If the hypothermia has become severe, notably if the patient is incoherent or unconscious, re-warming must be done under strictly controlled circumstances in a hospital. Bystanders should only remove the patient from the cold environment, give warm drinks (not too warm because it can lead to temperature shock) and get the patient to advanced medical care as quickly as possible.


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Hypothermia induces anti-inflammatory cytokines and inhibits nitric oxide and myeloperoxidase-mediated damage in the hearts of endotoxemic rats
From CHEST, 4/1/04 by Philip O. Scumpia

Study objectives: The impairment of cardiac contractility during endotoxemia involves induction of nitric oxide formation through a cascade of events initiated by overexpression of proinflammatory cytokines. We previously showed that hypothermia attenuates endotoxin-induced overexpression of nitric oxide in rat lungs. In the present study, we tested the hypothesis that hypothermia protects against endotoxin-induced myocardial inflammation by changing the balance of pro- and anti-inflammatory cytokines, inhibiting myeloperoxidase, an indicator of neutrophil activity, and inhibiting nitric oxide-mediated protein damage.

Design: Rats were randomized to treatment with either hypothermia (n = 6; 18 to 24[degrees]C) or normothermia (n = 6; 36 to 38[degrees]C). Endotoxin (15 mg/kg) was administered intravascularly to anesthetized animals, and heart tissue was harvested 150 min later.

Measurements and results: Using enzyme-linked immunosorbent assays (ELISAs), we found that hypothermia induced myocardial expression of the anti-inflammatory cytokines interleukin (IL)-4 and IL-10, while decreasing concentrations of the pro-inflammatory cytokines IL-1[beta] and growth-related oncogene/cytokine-induced neutrophil chemoattractant (rat homolog of IL-8). Electromobility shift assay revealed that hypothermia inhibited the nuclear translocation of nuclear factor-[kappa]B. Reverse transcriptase-polymerase chain reaction and Western blot assays revealed that hypothermia attenuated the endotoxin-induced overexpression of both inducible nitric oxide synthase (iNOS) messenger RNA and iNOS protein, respectively. Hypothermia also attenuated nitric oxide-mediated myocardial protein damage, as determined by a nitrotyrosine ELISA. Myocardial myeloperoxidase content, an indicator of neutrophil accumulation and oxidative activity, was also inhibited by hypothermia in endotoxemic rats.

Conclusion: These data demonstrate that hypothermia induces an anti-inflammatory cytokine profile, inhibits neutrophil aggregation, and inhibits the formation of nitric oxide during endotoxemia in the rat.

Key words: growth-related oncogene/chemoattractant; inducible nitric oxide synthase; interleukin-4; interleukin-10; lipopolysaccharide; nitrotyrosine: nuclear factor-[kappa]B

Abbreviations: ELISA = enzyme-linked immunosorbent assay; EMSA = electromobility shift assay: GRO/CINC-1 = growth-related oncogene/cytokine-induced neutrophil chemoattractant; gww = gram wet weight; IL = interleukin; iNOS = inducible nitric oxide synthase; LPS = lipopolysaccharide; NF = nuclear factor; PCR = polymerase chain reaction; SDS sodium dodecyl sulfate; TNF tumor necrosis factor


Heart failure is characterized by, myocardial depression and elevated proinflammatory cytokines. (1,2) Animal studies (3,4) suggest that elevated levels of the pro-inflammatory cytokine tumor necrosis factor (TNF)-[alpha] cause myocardial depression similar to that seen in experimental and clinical models of heart failure. In those patients with Gram-negative bacterial sepsis, the lipopolysaccharide (LPS) component of the bacterial membrane induces expression of various cytokines that act to depress myocardial function. (5) Administration of LPS alone into healthy humans causes a sepsis-like syndrome involving myocardial dysfunction. (6) Sepsis-induced expression of circulating cytokines, such as interleukin (IL)-1[beta] and TNF-[alpha], accounts for some of the humorally mediated myocardial dysfunction. (7) Endotoxin can cause local production of TNF-[alpha] and IL-8, which contributes to myocarchal dysfunction and neutrophil-mediated myocardial damage. (8-10) Induction of both circulating and intramyocardial cytokines therefore contribute to myocardial depression during Gram-negative sepsis.

During sepsis, the balance between pro- and anti-inflammatory cytokines shifts in support of the proinflammatory milieu. The proinflammatory cytokines IL-1[beta], TNF-[alpha], and interferon-[gamma], derived from T-helper type 1 cells, dominate the anti-inflammatory cytokines derived from T-helper type 2 cells, including IL-10 and IL-4. IL-10 has been shown to inhibit proinflammatory cytokine expression, (11-13) nuclear factor (NF)-[kappa]B activation, (14) and nitric oxide production. (15) Other benefits of IL-10 include promoting apoptosis in both neutrophils (16) and monocytes. (17) IL-4, however, has been shown to inhibit proinflammatory cytokine production by monocytes. (17-19) Increasing the concentrations of both IL-10 and IL-4 should therefore be expected to ameliorate the inflammatory consequences of sepsis, including myocardial dysfunction.

Hypothermia is often used as a means of preserving the heart during cardiopulmonary bypass and has also been used experimentally as means of inhibiting the inflammatory consequences of both severe brain trauma (20) and bacterial meningitis. (21,22) In cultured T cells, hypothermia induces an anti-inflammatory cytokine profile after an inflammatory stimulus. (23) Recently, we (24) demonstrated that hypothermia inhibits the intrapulmonary expression of inducible nitric oxide synthase (iNOS) and the intrapulmonary formation of nitric oxide induced by endotoxin in rats. In this study, we examined the effects of hypothermia on intramyocardial pro- and anti-inflammatory cytokine expression and nitric oxide-mediated myocardial injury during endotoxemia. We also investigated whether hypothermia caused myocardial inhibition of NF-[kappa]B, a key transcriptional mediator of LPS-induced proinflammatory cytokine and iNOS expression.


Surgical Preparation and Endotoxin Administration

Fifteen male Sprague-Dawley rats (Charles River Laboratory; Key Lois, FL) [280 to 350 g] were used for the experiments. All rats were fed a standard laboratory chow and were provided water ad libitum until the day of the experiment. The Institutional animals Use and Care Committee of University of Florida approved of the experiments, and the care and handling of the animals were in accordance with National Institutes of Health guidelines. Animals were preanesthetized with brief exposure to halothane followed by IM injections of ketamine (100 mg/kg) and xylazine (10 mg/kg). Twelve rats were randomized into two groups: hypothermia (n = 6; 18 to 24[degrees]C) and normothermia (n = 6; 36 to 38[degrees]C). The three remaining rats were sham instrumental (36 to 38[degrees]C; no LPS). The rats in the hypothermia group were placed on an ice pack, while the rats in the normothermia and sham groups were placed on a heating pad. A rectal temperature probe was inserted and temperature was maintained within the temperature range for the group. Polyethylene-50 catheters were inserted in the right carotid artery for continuous BP monitoring using a polygraph (model MP 100: Biopac; Santa Barbara, CA) and fluid infusion. A tracheostomy was then performed, and a 14-gauge catheter was secured in the trachea and connected to a mechanical breathing circuit.

After securing the airway, all animals were paralyzed with IV pancuronium bromide (1 mg/kg). Ventilation was controlled with a small animal ventilator (Rodent Model 683; Harvard Apparatus; South Natick, MA), using a 4-mL, tidal volume of room air at 35 breaths/min. Samples of arterial blood (70 [micro]L) were analyzed using an iSTAT 200 portable blood gas analyzer (Abbott Laboratories: Abbott Park, IL). Before starting the experiments, the ventilation rate was adjusted to ensure a PA[CO.sub.2] between 40 mm Hg and 45 mm Hg. The animals were allowed to acclimate to the experimental conditions for at least 20 min before collecting any data or administering endotoxin. Afterwards, a 15 mg/kg dose of Escherichia coli LPS (Sigma-Aldridge Corporation; St. Louis, MO) was administered intravascularly to induce endotoxemia in the normothermic and hypothermic groups. Animals were monitored for 150 min after the infusion of endotoxin or saline solution.

Tissue Sample Collection

The animals were killed with an overdose of saturated KCl. The heart was quickly removed, cut into four pieces, and each piece was snap frozen in liquid nitrogen and stored at--80[degrees]C for subsequent analysis.

Cytokine, Chemokine, and Nitrotyrosine Assays

IL-1[beta], IL-4, and IL-10 concentrations from supernatants derived from lung tissue homogenates were measured using Endogen Rat Interleukin ELISA kits (Pierce Endogen; Rockford, IL) and expressed as nanograms per gram wet weight (gww). Growth-related oncogene/cytokine induced neutrophil chemoattractant (GRO/CINC-1) concentrations were measured using the TiterZyme-EIA rat GRO/CINC-1 Enzyme Immunometric Assay Kit (Assay Designs; Ann Arbor, MI). Absorbencies were determined at 450 nm using a Powerwave X microplate reader (Biotek Instruments; Winooski, VT), and concentrations were calculated using the equation derived from a linear standard curves for each cytokine or chemokine. The nitrotyrosine concentration of sample extracts was determined using an enzyme-linked immunosorbent assay (ELISA) kit for nitrotyrosine (Cayman Chemicals; Ann Arbor, MI) according to the protocol of the manufacturer.

Nuclear Protein Extraction

Nuclear protein extracts were prepared from heart tissue homogenized in 2 mL of phosphate-buffered saline solution. All nuclear extraction procedures were performed on ice with chilled reagents using the NE-PER Nuclear and Cytoplasmic. Extraction Reagents (Pierce Endogen) according to the instructions of the manufacturer. The final supernatant derived from the nuclear pellet was placed in a clean, prechilled tube and stored at--80[degrees]C until electromobility shift assay (EMSA) or Western blot was done on the nuclear protein extracts.

EMSA for NF-[kappa]B

The NF-[kappa]B oligonucleotide probe (Promega Corporation; Madison, WI) [5'-AGT TGA GGG GAC TTT CCC AGG C-3'] was labeled with [[gamma]-[sup.32]P]adenosine triphosphate using T4 polynucleotide kinase (Life Technologies; Invitrogen; Carlsbad, CA) and purified in push columns (Stratagene; Cedar Creek, TX). For EMSA, 10 [micro]g of nuclear proteins were preincubated with EMSA buffer (12 mmol/L hydroxylethyl piparazinc-ethanesulfonic acid pH 7.9, 4 mmol/L Tris-HCl pH 7.9, 25 mmol/L KCl, 5 mmol/l, Mg[Cl.sub.2], 1 mmol/L ethylenediamine tetra-acetic acid, 1 mmol/L dithiothreitol, 50 ng/mL poly[d(I-C)], 12% glycerol volume/ volume, and 0.2 mmol/L phenylmethyl-sulfonylfluoride) on ice for 10 min before addition of the radiolabeled probe lot an additional 10 min. Protein-nucleic acid complexes were resolved using a nondenaturing polyacrylamide gel consisting of 5% acrylamide (29:1 ratio of acrylamide:bisacrylamide) and run in 0.5X TBE (45 mmol/L Tris-HCl, 45 mmol/L boric acid, 1 mmol/L ethylenediamine tetra-acetic acid) for 1 h at constant current (30 mA). Gels were transferred to Whatman 3 M paper (Whatman; Clifton, NJ), dried under a vacuum at 80[degrees]C for 1 h, and exposed to photographic film at--80[degrees]C.

Reverse Transcriptase-Polymerase Chain Reaction

Reverse Transcription: Total RNA was extracted from snap-frozen heart samples using TRIzol Reagent (Life Technologies). The integrity of isolated total RNA was determined using 1% agarose gel electrophoresis and RNA concentrations were determined by ultraviolet light absorbance at a wavelength of 260 nm. RNA samples were incubated with ribonuclease-free deoxyribo-nuclease 1 (Amersham Pharmacia Biotech; Piscataway, NJ) for 15 min at 37[degrees]C and extracted by a phenol-chloroform technique. Moloney murine leukemia virus reverse transcliptase and random hexamer primers (Ready-to-Go RT-PCR Beads; Amersham Pharmacia Biotech) were used to reaverse transcribe all messenger RNA species to complimentary DNA. The reaction incubated for 30 min at 42[degrees]C in a PTC-200 DNA Engine thermocycler (MJ Research; Watertown, MA). The complementary DNA samples were then incubated at 95[degrees]C for 5 min in the thermocycler to inactivate the reverse transcriptase. Samples were screened for genomic DNA contamination by carrying samples through the polymerase chain reaction (PCR) procedure without adding reverse transcriptase.

PCR: Reverse transcriptase-generated complementary DNA encoding iNOS and [beta]-actin were amplified using PCR. [beta]-actin, a housekeeping gene, was used as an internal standard. The oligonucleotide primer sequences (Table 1) were designed in accordance with published rat DNA sequences for iNOS (accession No. D14051) (25) and [beta]-actin (accession No. V01217 and No. J00691). (26)

The experimental conditions for iNOS, and [beta]-actin PCR reactions were as follows: initial denaturation at 95[degrees]C for 5 min followed by 32 cycles of amplification at 94[degrees]C for 1 min and 72[degrees]C for 1.5 min. A negative control for each set of PCR reactions contained water instead of the DNA template. All PCR products (8 [micro]L) were electrophoretically separated on a 1% agarose gel and then stained with ethidium bromide. A Gel Doc 2000 Gel Documentation System (Bio-Rad Laboratories; Hercules, CA) was used to visualize the PCR products. Densitometric techniques were then performed to quantify the DNA band densities using NIH software (Scion Corporation; Frederick, MD).

Immunoblotting Assay for iNOS and p65

For the detection of iNOS protein in whole-cell lysates, frozen heart samples were thawed immediately before analysis and homogenized in five volumes of boiling lysis buffer (1% sodium dodecyl sulfate [SDS], 1.0 mmol/L sodium orthovanadate, and 10 mmol/L Tris pH 7.4). After microwaving for 10 to 15 s, the crude homogenates were centrifuged at 15[degrees]C for 5 min at 16,000g, and the supernatants were collected for analysis. The protein concentration of each sample was measured using a BCA protein assay kit (Pierce Chemical). An equal volume of 2x sample buffer (250 mmol/L Tris pH 6.8, 4% SDS, 10% glycerol, 0.006% bromophenol blue, 2% b-mercaptoethanol) was added to all the samples and boiled for 3 to 5 min.

Proteins were separated by SDS-gel electrophoresis. Equal amounts of protein (65 [micro]g) were loaded onto each well of 7.5% Tris-glycine precast polyacrylamide gels (Bio-Rad Laboratories) mad separated by gel electrophoresis at 50 V of constant current for 180 min using a Mini-Protean electrophoresis system (Bio-Rad Laboratories). Lysate from cytokine-activated murine macrophages was used as a positive control. Then the proteins were transferred from gels to nitrocellulose membranes (Bin-Rad Technologies) at 100-V constant current for 60 min in transfer buffer (25 mM Tris, 190 mmol/L glycine, 20% methanol, 0.05% SDS). The nitrocellulose membranes were then immediately placed into blocking buffer (5% nonfat dry milk, 10 mmol/L Tris pH 7.5, 100 mmol/L, sodium chloride, 0.1% Tween-20) and left at room temperature for 60 min. After blocking, the membranes were incubated overnight at 4[degrees]C in primary antibody solution (1:1000 dilution in blocking buffer, routine monoclonal iNOS, IgG2a, antibody; Transduction Laboratories; Lexington, KY). Horseradish peroxidase conjugated sheep anti-mouse IgG antibody (1:2000 dilution in blocking buffer; Amersham Pharmacia Biotech) was used as a secondary antibody. Bound antibody was detected by chemiluminescence (ECL plus kit; Amersham Pharmacia B Biotech). The bands were expected at a size of 130 kd for iNOS.

For the detection of the p65 subunit of NF-[kappa]B in the nucleus, nuclear extracts were also subjected to the Western blot technique using a rabbit polyclonal anti-p65 primary antibody (1:500 dilution in blocking buffer; Santa Cruz Biotechnology; Santa Cruz, CA) and horseradish peroxidase conjugated anti-rabbit antibody (1:2000 dilution in blocking buffer; Amersham Pharmacia Biotech). Densitometric techniques were performed to quantify the protein band densities.

Myeloperoxidase Assay

Myelopemxidase activity was used to assess neutrophil accumulation in the heart tissue using a previously reported method. (27) Briefly, thawed heart samples were weighed and homogenized on ice in 0.01 mol/L K[H.sub.2]P[O.sub.4] at a ratio of 1 volume tissue to 15 volumes of buffer. After centrifugation at 10,000g for 20 min at 4[degrees], the pellets were resuspended by sonication in cetyltrimethyammonium bromide buffer (13.7 mmol/L cetyltrimethylammonium bromide, 50 mmol/L, K[H.sub.2]P[O.sub.4], 50 mmol/L acetic acid: pH 6.6) at a ratio of 1 to 5 weight to volume. The supernatant was kept for ELISA analysis (see previous text). The suspension was centrifuged again at 10,000g for 15 min. and the pellet was discarded. The supernatant was then incubated in a 60[degrees]C water bath for 2 h. Myeloperoxidase activity of the supernatant was measured by the [H.sub.2][O.sub.2]-dependent oxidation of tetramethylbenzidine. Absorbance was determined at 650 nm and compared with a linear standard curve.

Difference in the means among two or three treatment groups were detected using t test or one-way analysis of variance, respectively. Post hoc analyses using Student-Newman-Keuls test were performed if the analysis el variance revealed an effect of treatment. A significance level was set as 0.05. Data analyses were performed using SigmaStat for Windows, Version 2.03 (SPSS; Chicago. IL). Data are reported in the text and figures as means [+ or -] SE.


Effects of Hypothermia on Cytokine Expression

The concentration of IL-4 in the hearts of hypothermia-treated rats (1,825 [+ or -] 115 ng/gww) was more than threefold greater than that found in the normothermia (574 [+ or -] 196 ng/gww, p < 0.001) and sham (447 [+ or -] 83 ng/gww, p < 0.001) groups (Fig 1, top left, A). Similarly, IL-10 expression was induced by hypothermia (2,439 [+ or -] 185 pg/gww) compared to the normothermia (764 [+ or -] 129 pg/gww, p < 0.001) and sham (442 [+ or -] 79 pg/gww; p < 0.001) groups (Fig 1, top right, B).


The concentration of IL-1[beta] in the hearts of normothermia-treated rats (3.2 [+ or -] 0.2 ng/gww) was over threefold greater than that found in the hypothermia group (1.0 [+ or -] 0.1 ng/gww; p < 0.001; Fig 1, bottom left, C). Similarly, LPS caused an increase in GRO/ CINC-1 expression in the normothermia group (38 [+ or -] 5 ng/gww) compared to the control group (0.2 [+ or -] 0.1 ng/gww, p < 0.001; Fig 1, bottom right, D), and that increase was almost completely inhibited by hypothermia (0.6:3 [+ or -] 0.2 ng/gww, p < 0.001).

Effects of Hypothermia on NF-[kappa]B Activation and Nuclear Translocation

Results from the EMSA (Fig 2, top, A) confirm that hypothermia inhibits NF-[kappa]B activation and translocation into the nuclei of myocardial cells compared to normothermia. Densitometric analysis indicates there is a 35-fold increase in nuclear level of NF-[kappa]B (175 [+ or -] 10 U) compared to the hypothermia group (5 [+ or -] 4 U; p < 0.001). Similarly, a densitometric analysis of an immunoblot using an antibody to p65 (Fig 2, bottom, B), the active subunit of NF-[kappa]B, revealed that hypothermia inhibited the level of NF-[kappa]B (117 [+ or -] 10 U) in nuclear extracts as compared to the normothermia group (61 [+ or -] 13 U; p = 0.007).


Effects of Hypothermia on iNOS Expression

The relative density of iNOS messenger RNA normalized to [beta]-actin in rat myocardium was lower in the hypothermia group than the normothermia group (p = 0.001; Fig 3, top, A). Densitometric analysis of iNOS protein indicated higher levels of the protein in the myocardium of the normothermia group than in the hypothermia group (p = 0.013).


Effects of Hypothermia on Nitrotyrosine Formation

The formation of nitrotyrosine was induced by endotoxin in the normothermia group compared to the sham group (32 [+ or -] 5 pg/gww vs 11 [+ or -] 2 pg/gww, p < 0.05; Fig 4, top, A). Hypothermia (16 [+ or -] 1 pg/ gww) attenuated the endotoxin-induced increase in nitrotrosine formation in the heart tissue (p < 0.05).


Effects of Hypothermia on Myeloperoxidase

The normothermia group exhibited a 70-fold increase (p < 0.003) in heart myeloperoxidase concentration (1.43 [+ or -] 0.24 U/gww) compared to the sham group (0.02 [+ or -] 0.0004 U/gww; Fig 4, bottom, B). Hypothermia (0.15 [+ or -] 0.11 U/gww) attenuated the LPS-induced increase in myeloperoxidase concentration (p < 0.001) and was no different from the sham group (p > 0.05).


The anti-inflammatory benefits of hypothermia have been suggested to result from a generalized temperature-dependent decrease in metabolism. (28) However, our results suggest that the anti-inflammatory effects of hypothermia involve increased expression of some anti-inflammatory mediators. Further studies are needed which explore the use of IL-4 and IL-10 as agents that offer the therapeutic advantages of yet avoid the potential hazards of hypothermia therapy such as those reported with rewarming. (29,30)

The morbidity and mortality associated with sepsis has been linked to endotoxin induction of proinflammatory cytokines, most notably IL-1[beta] and IL-8. In our study, hypothermia inhibited the expression of these two cytokines but induced the expression of two anti-inflammatory cytokines, IL-4 and IL-10. It is likely that hypothermia stimulates T-helper type 2 cells to produce an anti-inflammatory cytokine profile. (23) Additionally, there is abundant evidence that IL-10 inhibits many aspects of endotoxin-mediated inflammation. (14-16,31) Although the mechanisms responsible for IL-10 and IL-4 anti-inflammatory effects are poorly understood, recent evidence suggests that IL-10 induces macrophages to express heme oxygenase-1, a stress-inducible protein with potential anti-inflammatory effect, via a p38 mitogen-activated protein kinase-dependent pathway. (32) Thus, we speculate that the increase in the levels of IL-10 and IL-4 in the hearts of hypothermic rats inhibits the inflammation caused by endotoxin seen in our experiment.

The activation of the key inflammatory mediator NF-[kappa]B has also been shown to be important in immunologic reactions resulting from endotoxemia such as cytokine (33,34) and nitric oxide (35,36) production. Others have shown that NF-[kappa] inhibition may have beneficial effects during endotoxemia. (37,38) It is likely that the decreased activation of NF-[kappa]B observed in the heart of hypothermia rats is responsible for the decreased expression of cardiac IL-1[beta], GRO/ CINC-1, and iNOS.

The overproduction of nitric oxide by iNOS has also been shown to be a major contributor to the pathogenesis of endotoxemia. Inhibition of iNOS activity or expression with various compounds during endotoxemia has been shown to improve cardiac function, (39) inhibit organ injury and shock, (41) and improve survival (42) in rodent models. In a previous study, (24) found that hypothermia inhibits endotoxin-induced intrapulmonary nitric oxide formation and regulates iNOS at the transcriptional level. We also found that hypothermia attenuated nitric oxide-mediated protein damage in the lungs as evidenced by decreased nitrotyrosine concentrations in the lung tissue. (24) Consistent with those data, we found that hypothermia attenuated the endotoxin-induced increase in iNOS messenger RNA and protein in heart tissue as well as the increased concentration of nitrotyrosine residues in the heart proteins of the endotoxin-treated rats. Thus, our data suggest that hypothermia protects against cardiopulmonary nitric oxide-related organ injury caused by endotoxin, perhaps by inhibition of locally formed nitric oxide.

Endotoxemia increases circulating levels of the neutrophil chemoattractant IL-8, (10) and also upregulates the neutrophil chemoattractant GRO/ CINC-1 (human IL-8 homolog) in rat cardiac myocytes. (43) In whole animals, endotoxin-induced accumulation of neutrophils in various organs can lead to multiple organ failure. Expression of myeloperoxidase, an enzyme involved in neutrophil oxidative bursts and a marker of neutrophil mediated injury, is increased in the myocardium during endotoxemia. (40,42,44) In our experiment, hypothermia decreased the concentration of GRO/CINC-1 and myeloperoxidase in rat hearts. These results suggest that hypothermia decreases both myocardial neutrophil accumulation and activity during endotoxemia.

This study may offer some insight into the cardio-protective effects of hypothermia that may translate to other systemic inflammatory disorders, such as cardiopulmonary bypass, during which hypothermia is often used. Similarities exist in the pathology of endotoxemia to that of surgical procedures involving cardiopulmonary bypass. Proinflammatory cytokine release, NF-[kappa]B activation, iNOS expression, and neutrophil accumulation occur during the ischemic conditions of cardiopulmonary bypass as well. A previous study (45) showed that hypothermic cardiopulmonary bypass results in a greater expression of IL-10 and better myocardial protection than normothermic cardiopulmonary bypass in piglets. Our data are consistent with those findings.

Several limitations to this study exist. One important limitation of this study is that rewarming the animals was not attempted. However, we prospectively designed this study to elucidate the effects of hypothermia on the parameters tested rather than study the rationale for hypothermia therapy. Interspecies differences between rats and humans do exist and are highlighted by the finding that our rats continued to have a normal cardiac rhythm at a core temperature of 18 to 24[degrees]C. At these temperatures, human subjects ordinarily spontaneously arrest their cardiac function. Another limitation of our study is the choice of endotoxin administration as our model for sepsis. Although endotoxin administration is a well-established protocol for systemic inflammatory responses, it does not exactly mimic a bacterial infection or the conditions associated with cardiopulmonary because. We chose endotoxemia as our model because of the simplicity of the study design and the ease to which we can test the anti-inflammatory properties of hypothermia in rodents.

In summary, hypothermia results in an induction of a T-helper type 2 response involving increased expression of IL-10 and IL-4 in the heart of endotoxemic rats. On the contrary, myocardial expression of the inflammatory cytokines IL-1[beta] and GRO/ CINC-1 was inhibited. Hypothermia also inhibited myocardial expression of nuclear NF-[kappa]B, iNOS, nitrotyrosine, and myeloperoxidase. These data are consistent with recent findings from our laboratory that hypothermia stimulates IL-10 production and reduces the proinflammatory response to endotoxin in the lungs of rats. (46) Whether IL-4 and/or IL-10 administration can mimic the therapeutic effects yet avoid the pathologic consequences of hypothermia warrants further investigation.


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Philip O. Scumpia, BS; Paul J. Sarcia, BS; Kindra M. Kelly, BS; Vincent G. DeMarco, PhD; and Jeffrey W. Skimming MD

* From the Departments of Pediatrics (Mr. Scumpia and Mr. Sarcia) and Physiology and Functional Genomics (Ms. Kelly), University of Florida, Gainesville, FL; and Department of Child Health (Dr. Skimming and Dr. DeMarco), University of Missouri, Columbia, MO.

This work was supported in part by grants from the National Institutes of Health (5M01RR000082-300655) and American Heart Association (0151064B) awarded to Dr. Skimming.

Manuscript received April 21,2003; revision accepted September 17, 2003.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail:

Correspondence to: Jeffrey W. Skimming, MD, Department of Child Health. One Hospital Dr, Columbia, MO 65211; e-mail:

COPYRIGHT 2004 American College of Chest Physicians
COPYRIGHT 2004 Gale Group

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