Imperial College London

DrChristopherMullington

Faculty of MedicineDepartment of Surgery & Cancer

Honorary Clinical Senior Lecturer
 
 
 
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c.mullington

 
 
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Building E - Sir Michael UrenWhite City Campus

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Summary

 

Publications

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10 results found

Chang G, Moiteiro Manteigas H, Strutton PH, Mullington CJet al., 2024, An evaluation of a healthy participant laboratory model of epidural hyperthermia: a physiological study., Int J Obstet Anesth, Vol: 57

BACKGROUND: Hyperthermia complicates 21% of cases of intrapartum epidural analgesia, but the mechanism is unclear. One hypothesis is that blockade of cholinergic sympathetic nerves prevents active vasodilation and sweating, thus limiting heat loss. Because labour increases heat production, this could create a situation in which heat production exceeds loss, causing body temperature to rise. This physiological study tested a novel laboratory model of epidural-related hyperthermia, using exercise to simulate the increased heat production of labour and surface insulation to simulate the effect of epidural analgesia. METHODS: Twelve healthy non-pregnant participants (six female) cycled an ergometer for two hours at 20 Watts (W) on two occasions: once with surface insulation (intervention) and once without (control). Core temperature, skin temperature (eight sites), and heat loss (eight sites) were recorded. Mean body temperature and heat production were calculated. Values are mean (SD). RESULTS: Exercise increased heat production on both visits (intervention 38 (18) W; control 37 (31) W; P = 0.94). Total heat loss was less on the intervention visit (intervention 115 (19) W; control 129 (23) W; P = 0.002). Core temperature increased on both visits (intervention 0.21 (0.37)°C; control 0.19 (0.27)°C; P < 0.001). The increase in mean body temperature was greater on the intervention visit (intervention 0.47 (0.41)°C; control 0.25 (0.19)°C; P = 0.007). CONCLUSIONS: This laboratory model predicts that labour epidural analgesia limits heat loss by >14 W. Once the model is validated, it could be used to test the efficacy of potential interventions to prevent and treat epidural-related maternal hyperthermia.

Journal article

Morton S, Kua J, Mullington C, 2023, Don't discount the epidural, BJOG: an International Journal of Obstetrics and Gynaecology, ISSN: 1470-0328

Journal article

Chaudhari N, Strutton PH, Wickham AJ, McGregor AH, Mullington CJet al., 2022, Heat stress associated with aerosol PPE and its impact, OCCUPATIONAL MEDICINE-OXFORD, ISSN: 0962-7480

Journal article

Morton S, Kua J, Mullington CJ, 2021, Epidural analgesia, intrapartum hyperthermia, and neonatal brain injury: a systematic review and meta-analysis, British Journal of Anaesthesia, Vol: 126, Pages: 500-515, ISSN: 0007-0912

BackgroundEpidural analgesia is associated with intrapartum hyperthermia, and chorioamnionitis is associated with neonatal brain injury. However, it is not known if epidural hyperthermia is associated with neonatal brain injury. This systematic review and meta-analysis investigated three questions: (1) does epidural analgesia cause intrapartum hyperthermia, (2) is intrapartum hyperthermia associated with neonatal brain injury, and (3) is epidural-induced hyperthermia associated with neonatal brain injury?MethodsPubMed, ISI Web of Knowledge, The Cochrane Library, and Embase were searched from inception to January 2020 using Medical Subject Headings (MeSH) terms relating to epidural analgesia, hyperthermia, labour, and neonatal brain injury. Studies were reviewed independently for inclusion and quality by two authors (Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach). Two meta-analyses were performed using the Mantel–Haenszel fixed effect method to generate odds ratios (ORs) and 95% confidence intervals (CIs).ResultsForty-one studies were included for Question 1 (646 296 participants), 36 for Question 2 (11 866 021 participants), and two studies for Question 3 (297 113 participants). When the mode of analgesia was randomised, epidural analgesia was associated with intrapartum hyperthermia (OR: 4.21; 95% CI: 3.48–5.09). There was an association between intrapartum hyperthermia and neonatal brain injury (OR: 2.79; 95% CI: 2.54–2.3.06). It was not possible to quantify the association between epidural-induced hyperthermia and neonatal brain injury.ConclusionsEpidural analgesia is a cause of intrapartum hyperthermia, and intrapartum hyperthermia of any cause is associated with neonatal brain injury. Further work is required to establish if epidural-induced hyperthermia is a cause of neonatal brain injury.

Journal article

Mullington CJ, Malhotra S, 2021, Hyperthermia after epidural analgesia in obstetrics, BJA Education, Vol: 21, Pages: 26-31, ISSN: 2058-5349

Journal article

Mullington CJ, Low DA, Strutton PH, Malhotra Set al., 2020, A mechanistic study of the tremor associated with epidural anaesthesia for intrapartum caesarean delivery, International Journal of Obstetric Anesthesia, Vol: 43, Pages: 56-64, ISSN: 0959-289X

BackgroundIt is not known if the tremor associated with an epidural top-up dose for intrapartum caesarean delivery is thermoregulatory shivering. A tremor is only shivering if it has the same frequency profile as cold stress-induced shivering. Thermoregulatory shivering is a response to a reduction in actual body temperature, whereas non-thermoregulatory shivering may be triggered by a reduction in sensed body temperature. This mechanistic study aimed to compare: 1. the frequency profiles of epidural top-up tremor and cold stress-induced shivering; and 2. body temperature (actual and sensed) before epidural top-up and at the onset of tremor.MethodsTwenty obstetric patients received an epidural top-up for intrapartum caesarean delivery and 20 non-pregnant female volunteers underwent a cold stress. Tremor, surface electromyography, core temperature, skin temperature (seven sites) and temperature sensation votes (a bipolar visual analog score ranging from −50 to +50 mm) were recorded.ResultsThe mean (SD) primary oscillation (9.9 (1.9) Hz) frequency of epidural top-up tremor did not differ from that of cold stress-induced shivering (9.0 (1.6) Hz; P=0.194), but the mean (SD) burst frequency was slower (6.1 (1.2) × 10−2 Hz vs 6.9 (0.7) × 10−2 Hz, respectively; P=0.046). Before the epidural top-up dose, the mean (SD) core temperature was 37.6 (0.6) °C. Between the epidural top-up dose and the onset of tremor the mean (SD) core temperature did not change (–0.1 (0.1) °C; P=0.126), the mean (SD) skin temperature increased (+0.4 (0.4) °C; P=0.002) and the mean (SD) temperature sensation votes decreased (−12 (16) mm; P=0.012).ConclusionThese results suggest that epidural top-up tremor is a form of non-thermoregulatory shivering triggered by a reduction in sensed body temperature.

Journal article

Mullington CJ, Kua J, Malhotra S, 2020, The Timing of Labor Epidurals in COVID-19 Parturients: A Balance of Risk and Benefit, ANESTHESIA AND ANALGESIA, Vol: 131, Pages: E131-E132, ISSN: 0003-2999

Journal article

Mullington CJ, Low DA, Strutton PH, Malhotra Set al., 2018, Body temperature, cutaneous heat loss and skin blood flow during epidural anaesthesia for emergency caesarean section, Anaesthesia, Vol: 73, Pages: 1500-1506, ISSN: 0003-2409

It is not clear how converting epidural analgesia for labour to epidural anaesthesia for emergency caesarean section affects either cutaneous vasomotor tone or mean body temperature. We hypothesised that topping up a labour epidural blocks active cutaneous vasodilation (cutaneous heat loss and skin blood flow decrease), and that as a result mean body temperature increases. Twenty women in established labour had body temperature, cutaneous heat loss and skin blood flow recorded before and after epidural top‐up for emergency caesarean section. Changes over time were analysed with repeated measures ANOVA. Mean (SD) mean body temperature was 36.8 (0.5)°C at epidural top‐up and 36.9 (0.6)°C at delivery. Between epidural top‐up and delivery, the mean (SD) rate of increase in mean body temperature was 0.5 (0.5) °C.h−1. Following epidural top‐up, chest (p < 0.001) and forearm (p = 0.004) heat loss decreased, but head (p = 0.05), thigh (p = 0.79) and calf (p = 1.00) heat loss did not change. The mean (SD) decrease in heat loss was 15 (19) % (p < 0.001). Neither arm (p = 0.06) nor thigh (p = 0.10) skin blood flow changed following epidural top‐up. Despite the lack of change in skin blood flow, the most plausible explanation for the reduction in heat loss and the increase in mean body temperature is blockade of active cutaneous vasodilation. It is possible that a similar mechanism is responsible for the hyperthermia associated with labour epidural analgesia.

Journal article

Mullington C, Wrench C, He J, Low D, Strutton P, Malhotra Set al., 2014, Thermal gradient: the primary driver of thermal perception?, Annual Congress of the Association-of-Anaesthetists-of-Great-Britain-and-Ireland (AAGBI), Publisher: WILEY-BLACKWELL, Pages: 38-38, ISSN: 0003-2409

Conference paper

Mullington CJ, Klungarvuth L, Catley M, McGregor AH, Strutton PHet al., 2009, Trunk muscle responses following unpredictable loading of an abducted arm, GAIT & POSTURE, Vol: 30, Pages: 181-186, ISSN: 0966-6362

Journal article

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