Hypothermia and surgery: immunologic mechanisms for current practice

Abstract

Objective: To examine cellular and immunologic mechanisms by which intraoperative hypothermia affects surgical patients.

Summary background data: Avoidance of perioperative hypothermia has recently become a focus of attention as an important quality performance measure, aimed at optimizing the care of surgical patients. Anesthetized surgical patients are particularly at risk for hypothermia, which has been directly linked to the development of sequelae, such as coagulopathy, infection, morbid myocardial events, and death after surgery. However, many of the underlying immunologic mechanisms remain unclear.

Methods: Venous blood samples from healthy volunteers were exposed for up to 4 hours to various temperatures following the addition of a 1 ng/mL lipopolysaccharide challenge. Innate immune function, assessed by the ability of monocytes to present antigen and coordinate cytokine release, was determined by qualitative and quantitative measurements of HLA-DR surface expression 2 hours following incubation, and proinflammatory tumor necrosis factor-alpha (TNF-alpha) and anti-inflammatory (IL-10) cytokine release in the first 4 hours.

Results: Monocyte incubation at hypothermic temperatures (34 degrees C) reduced HLA-DR surface expression, delayed TNF-alpha clearance, and increased IL-10 release. Conversely, hyperthermia (40 degrees C) increased monocyte antigen presentation and resulted in rapid decay of TNF-alpha. However, IL-10 release was also increased. Normothermia (37 degrees C) attenuated IL-10 release following the initial proinflammatory surge.

Conclusion: Hypothermia exerts multiple effects at the cellular level, which impair innate immune function, and are associated with increased septic complications and mortality. These findings provide a physiological basis for perioperative temperature monitoring, which is a valid surgical performance measure that can be used to reduce surgical complications associated with avoidable hypothermia.

FIGURE 1

Flow cytometer scatter plots showing negative control (upper image–A3) and positive CD14⁺/HLA-DR (lower image–A2) stained monocytes (gated–B).

FIGURE 2

Effect of temperature on change in HLA-DR MCF (n = 13).

FIGURE 3

Multiline Argon laser-scanning confocal microscopy digital images (Columns: 34°C–left; 37°C–middle; 40°C–right). Blue fluorescence represents fluorescein isothiocyanate-labeled CD14⁺ staining (A, B, and C). Red represents phycoerythrin-labeled HLA-DR (D, E, and F). Magenta represents co-localized staining which indicates surface HLA-DR since blue CD14⁺ exists only on the cell surface (G, H, and I). Red HLA-DR fluorescence intensity increases with increasing temperature (D, E, and F). A change in fluorescence color from blue to magenta with increasing temperature, therefore, specifically indicates an increase in surface HLA-DR expression. Note, at 40°C, a greater intensity of internalized HLA-DR (red) can be seen. This represents HLA-DR down-regulation since the stain is naturally incapable of permeating the cell membrane prior to binding. Therefore, actual surface HLA-DR receptor expression is considerably higher than estimated by flow cytometry at 40°C, when accounting for inevitable down-regulation of surface HLA-DR during monocyte preparation. In images D, F, G, and I, adjacent lymphocytes (red only) are visible (HLA-DR positive/CD14⁺ negative). Images F and I may represent monocyte antigen presentation in progress.

FIGURE 4

A and B, The effect of temperature on LPS-induced TNF-α (pg/mL) release at 30, 60, 120, and 240 minutes (A) and 120 minutes only (B, n = 9).

FIGURE 5

The effect of temperature on LPS-induced IL-10 release at 30, 60, 120, and 240 minutes (n = 9).

FIGURE 6

Lipopolysaccharide (LPS) dose-response curves on HLA-DR MCF showing maximal fluorescence at 1ng/mL LPS following 2 hours of incubation (n = 2).