CHAPTER 51

HYPOTHERMIA

Outline:

Definition

Temperature control

Pathophysiology

Causes of intra-operative heat loss

Methods of prevention

Methods of warming blood and IV fluids

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DEFINITION

Hypothermia describes subnormal body temperatures and an inability to

generate heat or compensate for heat loss.
It may be categorised as mild with temperatures ranging between 32 - 35
degrees centigrade, moderate at 27 - 32 degrees centigrade or severe when
the temperature is less than 27 degrees centigrade.
Body heat is lost through:
• Radiation (40%)
• Convection (30%)
• Evaporation (30%)
− 20% is lost through the skin
− 10% through respiration of which 8% is through evaporation
and 2% through warming the inhaled air
• Conduction (minimal)
Induced hypothermia is sometimes used in neurosurgical, cardiac and
vascular surgery to reduce damage to vital organs during periods of
hypoxia.
Accidental hypothermia is associated with
• Prolonged surgery
• Elderly and hypothyroid patients
• Exposure
• Near drowning

Signs of hypothermia
Signs of mild hypothermia are peripheral vasoconstriction, shivering,
decreased motor activity and CNS depression resulting in apathy or
amnesia.
Moderate hypothermia leads to further depression of the CNS resulting in
unconsciousness, cardiac arrhythmias and water diuresis with ensuing
dehydration.
Severe hypothermia decreases blood pressure, heart rate and may cause
ventricular fibrillation. At these temperatures the person will be in a coma
and without reflexes.

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TEMPERATURE CONTROL

The temperature control mechanism is situated in the hypothalamus where

temperature information from skin, central and neural tissues is processed.
• Two types of thermostatic neurons are located in the hypothalamus.
One type is affected by increased temperature, the other by decreased
temperature of the blood.
• Descending pathways connect mainly to cardiovascular and respiratory
centres in the brain stem and initiate heat loss or heat production
responses in an attempt to bring temperature back within normal levels.
A rise in the temperature of the blood causes an increase in the respiratory
rate, peripheral vasodilation (which increases radiation) and increased
perspiration.
Decreased temperature causes conservation of heat by vasoconstriction,
which reduces loss from radiation and by stimulating shivering. Heat
production is also raised by the increase of the thyrotropic function of the
anterior pituitary and a resulting increase in thyroid activity.
Temperature changes also cause obvious behavioural adjustments in
conscious adults eg movement to or from a heat source and the adding or
removing of clothing.

PATHOPHYSIOLOGY OF HYPOTHERMIA

Metabolic effects
There is a decrease in oxygen consumption and carbon dioxide production.
Serum glucose levels are increased as a result of catecholamine release and
a decrease in insulin production. Metabolic acidosis occurs resulting in an
increase in potassium to which the hypothermic heart is very sensitive.
Central nervous system
Cerebral blood flow is reduced, oxygen consumption is reduced, the victim
becomes sleepy at 33o C and cold narcosis follows at 30o C. The minimum
alveolar concentration of volatile agents is decreased therefore a smaller
concentration is needed and emergence from sleep may be delayed.
Blood
There is a decrease in plasma volume with an increase in viscosity.
Aggregation of platelets decreases their function and leads to
thrombocytopenia.

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Respiratory system
Shivering increases oxygen consumption 3-5 times and may hinder the
reading of the pulse oximeter.
There is reduced availability of oxygen to the tissues as a result of
respiratory depression, a fall in cardiac output, peripheral vasoconstriction
and increased blood viscosity. Increased solubility of carbon dioxide lowers
the arterial pressure of carbon dioxide further decreasing ventilatory drive.
The mechanism of hypoxic vasoconstriction is impaired resulting in an
increase in ventilation/perfusion mismatch and hypoxaemia. The oxygen
dissociation curve is shifted to the left decreasing oxygen delivery to the
tissues.
Cardiovascular system
Hypothermia can induce ventricular ectopic beats leading to unresponsive
ventricular fibrillation or to bradycardia leading to unresponsive asystole.
Vasoconstriction increases systemic vascular resistance increasing after load
and myocardial oxygen demand, causing tissue hypoxia and acidosis
although coronary blood flow is well maintained initially.
Urinary system
Renal blood flow and the glomerular filtration rate are decreased.
Decreased sodium reabsorption causes impairment of concentration of urine
leading to cold diuresis and hypovolaemia.
Liver
The blood supply to the liver is diminished slowing down liver function and
the metabolism of drugs.

CAUSES OF INTRA-OPERATIVE HEAT LOSS

For the anaesthetist, hypothermia as a result of prolonged surgery is the

most important and most common cause.
Patient factors
There is loss of movement, a reduced capacity to shiver, exposure and an
increased surface area with increased evaporation. The introduction of cold
fluids, either intravenously, as peritoneal lavage or bladder washout, also
contributes to heat loss. (For methods of warming infused fluids see below).
Infants have an increased surface area to body mass ratio and therefore
loose heat more rapidly than adults. Patients with burns, severe injuries and
those who are hypothyroid are predisposed to greater heat loss, as are the
elderly who have decreased sympathetic activity.

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Anaesthetic factors
Dry anaesthetic gases cause extra heat and moisture loss.
Many anaesthetic drugs, such as thiopentone and halothane, cause
vasodilatation. Opiates decrease vasoconstriction and volatile agents
interfere with thermoregulation in the hypothalamus. Subarachnoid blocks
also cause vasodilatation, inactivate muscular movement and block sensory
input to the thermoregulatory centre.
Surgical factors
Prolonged exposure of abdominal organs, abdominal lavage and bladder
washouts all lead to a significant drop in body temperature.

METHODS OF PREVENTION OF HEAT LOSS DURING SURGERY

• The use of heat and moisture exchange filters (HME) helps to reduce
heat loss from the respiratory tract.
• Warming the fluids given IV or used for lavage reduces further heat
loss from exposed tissues and cold fluids.
• Some form of external body warming such as a hot air blanket, a
covered hot water bottle or covering of head and exposed limbs by
drapes or even woollen garments.
• Raising the ambient temperature of the operating room even if this may
become uncomfortable for staff.

SIMPLE METHODS OF WARMING BLOOD AND IV FLUIDS

• Put the container of blood or plasma in lukewarm water before

administering it.
• The infusion set tubing can be passed through a warm bath or under the
warming blanket.
• Use a blood warmer. This consists of a very long plastic coil which is
immersed in a water bath maintained at about 37oC. The aim is to
deliver blood to the patient at near body temperature without causing
blood damage. (See Chapter 47)

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