Peritoneal dialysis to induce hypothermia in a head-injured patient: Case report

TRAUMA Peritoneal Dialysis to Induce Hypothermia

in a Head-Injured

Patient: Case Report Leopold0 C. Cancio, M.D., William Surgery, Nephrology,

General

G. Wortham,

and Neurosurgery, Brooke Army Medical Center, Fort Sam Houston, Texas

Cancio LC, Wortham WG, Zimba F. Peritoneal dialysis to induce hypothermia in a head-injured patient: case report. Surg Nemo1 1994;42:303-7. Hypothermia

is of proven

and may be of benefit dialysis

benefit

in blunt

is a fast, effective

ized hypothermia.

intracranial

diuresis,

mia was associated and intracranial method injured KEY

for

(34.5-36”

a severe head injury, with

unresponsive

with prompt

inducing

general-

in which peritoneal

to hyperventila-

and barbiturate

pressure.

Peritoneal

of inducing

mild hypothermia

who sustained

ischemia,

head injury.

A case is reported

hypertension

tion, osmotic

in cerebral

method

dialysis was used to induce C) in a patient

coma.

control

Peritoneal

hypothermia

Hypother-

of temperature

dialysis is a useful in the

blunt

head-

patient.

WORDS:

Brain injuries;

Hypothermia,

induced;

Peritoneal

dialysis.

Hypothermia

has been used intermittently

for cerebral

protection since the 1930s [9}. Clinical experience and laboratory studies in both cardiovascular and neurologic surgery confirm the beneficial role of hypothermia in ischemic injury. Recently, prospective, controlled studies have appeared that tend to support the use of mild hypothermia

(32-34.5”

C)

injury as well [7,21,27]. Peritoneal dialysis (PD) highly effective method thermia {b]. We present

in victims

Case

of blunt

is an infrequently

head

used but

of inducing generalized hypothe first reported case in which

PD was used to induce mild hypothermia in a blunt head-injured patient with fever and intracranial

(34.5-36” C), uncontrollable

hypertension.

Report

A 25-year-old parked vehicle

man was the unrestrained driver of a that was struck from the rear. His Glas-

Address reprint requests to: Dr. Leopold0 C. Cancio, General Surgery Service, Brooke Army Medical Center, Fort Sam Houston, TX 78234. Received November 2, 1993; accepted April 19, 1994. 0

1994 by Elsener Science Inc.

M.D., and Frank Zimba, M.D.

gow Coma Scale score was 3, although ing was noted after intubation pupils

were bilaterally

extensor

postur-

and hyperventilation.

fixed and dilated.

His

Spontaneous

respirations were present. Laboratory data were unremarkable except for a blood alcohol level of 86 mgl% and

a urine

toxin

screen

positive

for

marijuana.

A

computed tomography scan of the head was performed, revealing an acute left frontoparietal subdural hematoma with shift of the midline. Mannitol was given intravenously.

His pupils

became

minimally

reactive

to light,

and he developed decorticate posturing in response to pain. An emergent left frontotemporal craniotomy was performed. Barbiturate coma was induced intraoperatively in light of marked cerebral edema. Postoperatively, he was hyperventilated to maintain a pC0, of 27-28 mm Hg. Barbiturate coma was continued with pentobarbital

at 1.2 mg/kg/h,

and an electroencephalogram

confirmed achievement of burst suppression. Intracranial pressures (ICPs) remained less than 20 mm Hg for the first 8 postoperative hours. However, over the next 24 hours his ICPs persistently increased to as high as 32 mm Hg. Ongoing hyperventilation to a pC0, of 24-28 mm Hg, infusion of 25-50

g of mannitol

every 4 hours, and maintenance

of pentobarbital coma did not control the ICP. Meanwhile he developed copious purulent sputum and became febrile

with a maximum

temperature

(axillary), despite application of topical kets, ice packs, and the administration

of 38.9”

C

cooling blanof acetamino-

phen suppositories. The Nephrology catheter (Tenkhoff

Service was consulted and a PD type) was placed using Y-TECH

percutaneous technique at the bedside approximately 36 hours post-injury (14). PD was initiated using cooled dialysate and a dwell time of 30 minutes. 1.5 L of Dianeal (Travenol, Deerfield, IL) dialysate were used, with 1.5% glucose (osmolarity 346 mOsm/L) and 4 mEq KCl/L. The procedure was repeated as often as needed to maintain a core temperature of 34.5-36” C, as measured by pulmonary artery catheter-initially once an hour. It was soon possible to replace refrigerated dialysate at approximately 5’ C with room temperature dialysate. PD was continued for 8 days. 0090.3019/94/$7.00

304

Surg Neurol 1994;42:303-7

Cancio et al.

105 100 95 B 0

90 85 80 75 70

30 25

a y20

15 10 5

I- 38.5 35.5 34.5

, , . . . . , . . . , , . , . , , . . . ., 40

50

80

70

80

Hourafterinjuty

PD

begun at

6 hours

post

injury

Figure 1. Data fm the jirst 80 hours after injury. Abbreviations: CCP, cerebral perfusion pressure (mm Hg); ICP, intracranial pressure (mm Hg); T (C), temperature in degrees centigrade; PCO,, partial pressure of artwial carbon dioxide (mm Hg); osm, sw.wn osmolarity (VzOsmlL).

PD was immediately effective in lowering core temperature and was accompanied by immediate control of intracranial pressure (Figure 1). There was no hemodynamic instability; cerebral perfusion pressure (CPP) improved as well. There was no significant change in serum electro-

lytes or glucose. Intravenous mannitol was discontinued on postoperative day 3. Pentobarbital was slowly weaned over postoperative days 4-7. Discontinuation of PD on postoperative day 9 was not accompanied by any rebound in intracranial pressure. Follow-up computed tomography

Hypothermia

by Peritoneal

Dialysis

Surg Nemo1 1994;42:303-7

scans of the head revealed a large left frontoparietal infarct. Prior to his transfer to a long-term care facility, his Glasgow Coma Scale score was 6.

[15].

Cool peritoneal

patient

with

dialysate

305

has been used to cool a

meningococcal

sepsis

and

hyperpyrexia

[17]. In sum, there are three clinical reports in the literature in which peritoneal lavage or dialysis has been used to lower body temperature. A disadvantage

Discussion PD

enabled

rapid

institution

of mild

hypothermia

in

this febrile patient where external cooling with blankets and ice packs had failed, and was associated with rapid control of intracranial hypertension. Other treatments (barbiturates,

mannitol,

hyperventilation)

were contin-

ued and may have acted synergistically. Nonetheless, if hypothermia is proven beneficial in head injury, PD may be a convenient

approach.

The dialysate used was hyperosmolar at 346 mOsm/L. In theory, this might potentiate the effect of mannitol by drawing water into the peritoneal cavity, thus decreasing intravascular volume, increasing plasma osmolarity, and decreasing intracellular water and ICP. In this case no net loss of fluid from the patient

during

PD was observed, suggesting that PD did not affect intracellular water and thus ICP by this mechanism. The

history

of PD

(or,

more

generally,

peritoneal

lavage) as a method of altering body temperature began in 1877 with Wegner, who demonstrated that peritoneal lavage with cold normal saline can rapidly lower core temperature in the rabbit 1341. During the 1960s induction peritoneal

of hypothermia by irrigation of the open cavity was advocated as an adjunct to liver

surgery [20}. In 1967 warm PD was used in the successful treatment of a patient who had overdosed on pentobarbital, became hypothermic to 21’ C, and suffered prolonged asystolic cardiac arrest 1197. There have been several subsequent reports of PD in rewarming E24,251. The use of hypothermia surgery

and difficulties

in cardiac

in controlling

and neurologic temperature

dur-

in the

of both peritoneal

emergency

requires

setting

the services

is that

lavage and dialysis catheter

of a specialist

placement

and can be time-

consuming [35]. On the other hand, peritoneal cooling may be faster than other methods once instituted. This probably

represents

the fact that the surface area of the

peritoneum is approximately a whole IS]. The peritoneal the skin,

equal to that of the skin as vasculature, unlike that of

does not react to cold with

Lb]; and it is intimately

related

large vessels.

In a canine

showed

that

cold

provides

faster cooling

heat stroke

peritoneal

vasoconstriction

to the aorta and other model,

lavage,

than external

one study

at 0.56”

Cimin,

application

of bags

of ice slush (0.11’

C/min) or passive cooling

in 27” C

air (0.06”

Lb]. On

a similar

study

C/min)

showed

spraying

no difference

tap water 1351.

This

may not, however, intensive

hand,

in cooling

on dogs

C/min/ma), and continuous C/min/mz)

the other with

rates

a large

iced peritoneal

method

between

fan (0.18’

lavage (0.17’

of evaporative

be as suited for long-term

cooling use in an

care unit as is PD.

Risks of PD that must be considered ing, catheter infection with or without

include bleedperitonitis, in-

jury

compromise

to bowel

or bladder,

patients

with

chronic

(COPD),

exacerbation

respiratory

obstructive of abdominal

pulmonary hernia,

in

disease

volume

de-

pletion, hypokalemia, hyperglycemia, and other metabolic changes. Absolute contraindications include severe COPD and peritoneopleural communication [23}. Available data suggest that PD is safe in head-injured patients,

whereas hemodialysis

case reports

describe

safe PD

is not. For example, in the treatment

two

of pa-

ing surface cooling increased interest in hypothermic PD 1261. Trinkle in 1971 induced hypothermia to 20°

tients who develop subdural hematomas while on hemodialysis [5,317. One reason for this is avoidance of the

C in dogs, enabling was no histologic

modialysis

successful circulatory evidence of visceral

arrest; there injury. He

“dialysis

disequilibrium patients

syndrome,”

recognized

for years; it may feature

in he-

headache,

adopted this method in the repair of total anomalous pulmonary venous return in a febrile infant 1327. A technique using separate afferent and efferent intraperitoneal catheters and continuously circulating cold dialy-

confusion, agitation, twitching, convulsions, coma, and occasional death [91. The pathophysiology of this syndrome is unclear, but it may involve rapid changes in

sate was then tested in rabbits {29]. Subsequently, cold PD was proposed as emergency treatment for malignant hyperthermia, and cooling a normal volunteer with 20” C dialysate was performed 1131. Peritoneal lavage as treatment for heat stroke was studied in a dog model, and was found to be faster than external ice packs or passive cooling in room air lb]. This technique has been used successfully in humans

intracellular

the blood-brain

gradient

acidosis,

of urea or other

and/or cerebral

edema

substances, [1,10,16,

33,371. This syndrome is unusual in PD and unknown in continuous ambulatory PD, probably because PD is a more gradual process than conventional hemodialysis [18]. Neurologic symptoms have been observed during PD, but actually may be due to hyperosmolarity, hypoglycemia, alkalosis, or other metabolic changes without cerebral edema 1231. Whereas studies in uremic neuro-

Surg Nemo1

306

Cancio

et al.

1994;42:303-7

surgical patients [4,18,30,37), tients 1281, uninjured uremic

uninjured dogs 112,281,

dogs [28]

ICP

rises during

pressure

increases

indicate

that

uremic paand normal conventional

hemodialysis,

similar

served during

PD in three uremic neurosurgical

[4,18]. On the other hand, computed

were

not obpatients

tomography

scan-

out or controlled

is probably

contraindicated,

[7,21,27]; measures

shivering is prevented by the pharmacologic already in place in these patients (narcotics,

muscle

relaxants,

density (attributable to increased intracellular water) in both hemodialysis and intermittent PD patients, but

possible

with PD should not be hazardous.

showed

Conclusion

ning

showed

tients.

similar

no change

post-dialysis

decreases

in continuous

ambulatory

In sum, the dialysis equilibrium

concomitant pressure,

cerebral

edema

in cerebral

and increased

has not been extensively

PD pa-

syndrome,

with

intracranial

studied

in neurosur-

gical patients subjected to peritoneal dialysis; logically it would be unlikely, particularly in non-uremic patients. Furthermore, pressure, ICP.

although

the change

PD does raise intra-abdominal

is probably

Intra-abdominal

pressure

not sufficient rises linearly

ume infused up to as high as 12 cm H20

to affect with

vol-

This

is the first reported

Hg

[l I].

This

indirect

unlikely to affect ICP pressure mechanism. PD should

suggests

injury

or with

trauma patients

with perforated

of interest

PD

is

after repair of

in round-the-clock

undergone

Blunt

PD with

PD with medicated

for patients

with

opinions

the authors

via

PD

or assertions

contained

herein

and are not to be construed of the Army

are the private

views of

as official or as reflecting or the Department

the

of Defense.

References 1. Arieff AI, Massry SG, Barrientos A, Kleeman CR. Brain water and electrolyte metabolism in uremia: effects of slow and rapid hemodialysis. Kidney Int 1973;4:177-87. 2.

bowel and postoperative

dialysate 122). There is a resurgence

sate as a treatment

cooling

of 60 mm that

gross peritonitis.

acute renal failure have successfully antibiotic-containing

to 15

by an intraabdominal

be safe for use in patients

intra-abdominal

case in which PD was used to

was 5.1 mm

pressure

evidence adversely

segment

increase

at a compartment

of onset

(8.8 mm Hg)

views of the Department

and that the maximum

rapidity

management of severe head injury, represents a practical technique.

mm Hg with inflation mm Hg,

The

dialysate and occasionally with refrigerated dialysate. If mild hypothermia proves to be a useful adjunct to the

The

Hg over baseline

barbiturates).

induce hypothermia in head injury. We found the technique to be fast, efficient, and fairly risk-free, for a patient in whom topical cooling had failed. The patient was cooled for the most part with room temperature

with 3 L of dialysate 127. A study of the pneumatic antishock garment showed that ICP increased only 2.4 of the abdominal

as hypo-

thermia is associated with coagulopathy in patients with major truncal injuries 131. Mild hypothermia is without significant side effects,

dialy-

generalized

fecal

Bargman JM. Complications of peritoneal increased intra-abdominal pressure. Kidney 4O):S75-S80.

dialysis related to Int 1993; 43(suppl

AF. The effects of hypothermia and injury severity on 3. Bernabei blood loss during trauma laparotomy. J Trauma 1992; 33:835-9. 4.

Bertrand Y, Hermant A, Mahieu P, Roels J. Intracranial pressure changes in patients with head trauma during hemodialysis. Intensive Care Med 1983;9:321-3.

peritonitis 1361. (On the other hand, the prior presence of an enterostomy or a urostomy may increase the risk of infection and is a relative contraindication [23}.) Blood in

G, Sherrard D, Mathews M. Peritoneal dialysis: a 5. Bidwell temporizing means for hemodialysis patients with subdural hematomas. Nephron 1977;18:352-3.

the peritoneal

6.

cavity is not a contraindication.

Insofar as the sooner after injury begun, the more likely it is to benefit question

arises whether

hypothermic

hypothermia the patient, PD might

is the

be in-

stituted in the emergency department. Diagnostic peritoneal lavage is commonly performed during trauma resuscitation with acceptable morbidity. But the placement of a PD catheter intended for prolonged use takes longer, requires meticulous sterility, and presumes additional training. Thus, external cooling will probably

Bynum G, Patton J, Bowers W, Leav I, Hamlet M, Marsili M, Wolfe D. Peritoneal lavage cooling in an anesthetized dog heatstroke model. Aviat Space Environ Med 1978;49:779-84.

7. Clifton GL, Allen S, Plenger PM, Berry J, Koch SM. A phase II study of systemic hypothermia in severe brain injury (abstr). J Neurosurg 1993;78:347A. 8. Condon BE, Malangoni MA. Peritonitis abscesses. In: Schwartz SI, ed. Principles New York: McGraw-Hill, 1984;1391-1419. 9.

and intraabdominal of surgery. 4th ed.

Fay T. Observations on generalized refrigeration severe cerebral trauma. Assoc Res Nerv Men Dis 24:611-9.

in cases of Proc 1945;

prove more convenient than PD during initial resuscitation. On the other hand, PD may occasionally be an

10.

Fraser CL, Arieff AI. Nervous Ann Intern Med 1988;143-53.

option

11.

Gardner SR, Maul1 KI, Swensson EE, Ward JD. The effects of the pneumatic antishock garment on intracranial pressure in man: a prospective study of 12 patients with severe head injury. J Trauma 1984;24:896-900.

for initial

use by surgeons

in military

settings

in

which electricity is unavailable. Secondly, the induction of hypothermia before major hemorrhage has been ruled

system

complications

in uremia.

Hypothermia

by Peritoneal Dialysis

Surg Nemo1 1994;42:303-7

12. Gilliland KG, Hegstrom RM. The effect of hemodialysis on cerebrospinal fluid pressure in uremic dogs. Trans Am Sot Artif Intern Organs 1963;9:44-50. 13. Gjessing J, Barsa J, Tomlin PJ. A possible means of rapid cooling in the emergency treatment of malignant pyrexia. Br J Anaesth 1976;48:469-73. 14. Gokal R, Ash SR, Helfrich GB, Holmes CJ, Joffe P, Nichols WK, Oreopoulos DG, Riella MC, Slingenemeyer A, Twardowski ZJ, Vas SI. Peritoneal catheters and exit-site practices: toward optimum peritoneal access. Perit Dial Int 1993;13: 29-39. 15. Horowitz BZ. The golden hour in heat stroke: use of peritoneal lavage. Am J Emerg Med 1989;7:616-9. 16. Kennedy AC, Linton AL, Luke RG, Renfrew S, Dinwoodie A. The pathogenesis and prevention of cerebral dysfunction during dialysis. Lancet 1964;1:790-3.

307

25.

Reuler JB, Parker RA. Peritoneal dialysis in the management of hypothermia. JAMA 1978;240:2289-90,

26.

Rhode CM, Jennings WDJ, Pittman W. Experimental total body hypothermia: a comparison of three methods of production. Southern Med J 1970;63:1353-6.

27. Shiozaki T, Sugimoto H, Taneda M, Yoshida H, Iwai A, Yoshioka T, Sugimoto T. Effect of mild hypothermia on uncontrollable intracranial hypertension after severe head injury. J Neurosurg 1993;79:363-8. 28. Sitprija V, Helms JH. Preliminary observations on the change in intracranial pressure and intraocular pressure during hemodialysis. Trans Am Sot Artif Intern Organs 1962;8:300-6. 29. Sperling DR, Beran AV. Hypothermia and rewarming by peritoneal dialysis and temperature-controlled inhalate. Ann Thorac Surg 1976;21:151-7.

due to lavage.

30. Thicoipe M, Stoiber HP, Maurette P, Leger A, Cochard JF. Variations de la pression intracranniene chez le traumatisme cranien grave in hemodialyse. Ann Fr Anesth Reanim 1988; 7:336-g.

18. Krane NK. Intracranial pressure measurement in a patient undergoing hemodialysis and peritoneal dialysis. Am J Kidney Dis 1989;13:336-9.

3 1. Tietjen DP, Moore JJ, Gouge SF. Hemodialysis-associated acute subdural hematoma: interim management with peritoneal dialysis. Am J Nephrol 1987;7:478-81.

19. Lash RF, Burdette JA, Ozdil T. Accidental profound hypothetmia and barbiturate intoxication: a report of rapid “core” rewarming by peritoneal dialysis. JAMA 1967;201:269-70.

32. Trinkle JK, Franz JL, Furman RW, Mobin-Uddin K, Bryant LR. Circulatory arrest during deep hypothermia induced by peritoneal dialysis. Arch Surg 1971;103:648-9.

20. Little JM, Goodman AH. Peritoneal hypothermia: and indications. Surgery 1967;62:346-51.

33. Wakim KG. The pathophysiology of the dialysis disequilibrium syndrome. May Clin Proc 1969;70:129-37.

17. Khan IH, Henderson IS, Mactier RA. Hyperpyrexia meningococcal septicemia treated with cold peritoneal Postgrad Med J 1992;68: 129-31.

physiology

21. Marion DW, Obrist WD, Carlier PM, Penrod LE, Darby JM. The use of moderate therapeutic hypothermia for patients with severe head injuries: a preliminary report. Neurosurgery 1993; 79~354-62.

34. Wegner G. Chirurgische Bemerkungen uber die Peritonealhohle, mit besonderer Berucksichtigung der Ovariotomie, Arch Klin Chir 1887;20:51-145.

22. Matas AJ, Payne WD, Simmons RL, Buselmeier TJ, Kjellstrand CM. Acute renal failure following blunt civilian trauma. Ann Surg 1977;185:301-6.

35. White JD, Kamath R, Nucci R, Johnson C, Shepherd S. Evaporation versus iced peritoneal lavage treatment of heatstroke: comparative efficacy in a canine model. Am J Emerg Med 1993; ll:l-3.

23. Mion C. Practical use of peritoneal dialysis. In: Maher JF, ed. Replacement of renal function by dialysis. 3rd ed. Boston, MA: Kluwer Academic Publishers, 1989:537-89.

36. Wilson SE. A critical analysis of recent innovations treatment of intra-abdominal infection. Surg Gynecol 1993; 177 (suppl):ll-17.

24.

37. Yoshida S, Tajika T, Yamasaki N, Tanikawa T, Kitamura K, Kubo K, Lyden PD. Dialysis dysequilibrium syndrome in neurosurgical patients. Neurosurgery 1987; 20:71621.

Patton JF, Doolittle WH. Core rewarming by peritoneal dialysis following induced hypothermia in the dog. J Appl Physiol 1972;33:800-4.

in the Obstet