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Critical Care  2012 

Hypothermia in the operating theatre

DOI: 10.1186/cc11275

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Cerebral ischaemia results from a reduction or complete loss of cerebral blood flow (CBF) and lack of cerebral oxygenation, followed by depletion of ATP, dysfunction of ATP-dependent membrane pumps and subsequently occurrence of anoxic depolarisation. A large amount of glutamate is released from the intracellular space into the extracellular space, causing excitotoxic injury by stimulating N-methyl-D-aspartate (NMDA) receptors and triggering calcium influx. Increased intracellular calcium levels per se amplify injury by increasing calcium permeability and glutamate release via second messenger mechanisms. These acute cascades lead to necrotic neuronal death by interfering with the mitochondrial respiratory chain. Ischaemia and reperfusion further enhance excitotoxicity by providing oxygen as a substrate for several enzymatic oxidation reactions, thereby generating products of reactive oxygen species in large quantities. These free radicals enhance protein oxidation and lipid membrane disintegration and in conjunction with blood-brain barrier (BBB) disruption further contribute to ischaemic necrosis. Apoptosis also occurs in cerebral ischemia, with antiapoptotic proteins being selectively upregulated in surviving neurons and proapoptotic proteins being highly expressed in dying cells.The first controlled attempts to cool the human brain were undertaken by the neurosurgeon Temple Fay in 1938 [1]. Irrigating the brain directly with ice water and sometimes achieving solid parenchymal freezing, he claimed 'extremely gratifying results' in a paper on 'local and generalized refrigeration of the human brain'. Over time, many mechanisms have been proposed regarding the neuroprotective effect of hypothermia. First, hypothermia results in a temperature-dependent decrease of oxygen and glucose metabolism; that is, a 10°C decrease in temperature reduces ATP consumption and the cerebral metabolic rate (CMR) of oxygen, glucose, and lactate twofold to fourfold [2]. Second, intra-is


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