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PERIOPERATIVE HYPOTHERMIA, PREVENTION AND MANAGEMENT TUTORIAL OF THE WEEK NUMBER 117 20THTH OCTOBER 2008
Dr.K.K.Ramaswamy, Wexham Park Hospital, UK. Correspondence to kramaswamy@doctors.org. k
The aim of this tutorial is to discuss the causes and management of hypothermia under anaesthesia. Please answer the following uestions !efore reading the article. "# %# &# '# )# What are the pro!lems with hypothermia in theatre$ What are the mechanisms of heat loss under anaesthesia$ What are the different phases of heat loss under anaesthesia$ (ow can hypothermia !e prevented$ (ow would you manage inadvertent hypothermia$

INTRODUCTION
*ore temperature is one of the most closely maintained physiological parameters as en+yme systems in the !ody have narrow temperature ranges in which they function optimally. The normal core temperature range of adult patients is !etween &,.)-* and &..)-* and hypothermia can !e defined as core !ody temperature less than &,-*. /nadvertent perioperative hypothermia is a common !ut preventa!le complication. 0egular measurement and recording of temperature is the key to prompt identification and its management.

CONSEQUENCES OF HYPOTHERMIA
/ncreased perioperative !lood loss1coagulopathy2 the clotting cascade is en+ymatic and platelet function is temperature dependent. 3onger post anaesthetic recovery due to altered drug meta!olism Postoperative shivering and increased o4ygen consumption Thermal discomfort *ardiac events including myocardial ischaemia5 arrhythmias 6elayed wound healing /ncreased rates of surgical wound infection 3onger hospital stay 6eath

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CAUSES OF HYPOTHERMIA UNDER ANAESTHESIA

Altered responses to heat loss due to anaesthesia 8e.g. lack of shivering# /ncreased heat loss9environment e4posure *ooling effect of cold anaesthetic gases and intravenous fluids 0educed heat production due to reduced meta!olic activity

T !" #$%&# '($)* + $,% # Phase "10edistri!ution -).&'%-/) /, * ) #$0 $)$ +%( +-$
17.2 17 14.2 14 12.2 12 13.2 13 T 11.2 !" #$%&# -) D *# + 11 0 2 Phase %13inear

Phase &1 Plateau

T-! -) (/&#+
Figure 1. Temperature changes after induction of general anaesthesia

PHASE 1 5 REDISTRIBUTION This is due to vasodilatation causing redistri!ution of heat from core to periphery following
induction of anaesthesia. :ody heat content initially remains unchanged.

PHASE 2 5 LINEAR PHASE

There is a more gradual reduction in core temperature of a further "9% o* over the ne4t %9&hrs. This usually !egins at the start of surgery as the patient is e4posed to the cold cleaning fluids5 and e4posure to the cold theatre environment. (eat loss e4ceeds heat production. The various modes of heat loss are2

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Radiation2 contri!utes to most of heat loss 9 appro4imately '-; and is proportional to the environment1core temperature difference 8to the power of four#. Convection up to &-; and is due to loss of heat to air immediately surrounding the !ody. /t is proportional to the velocity of the air. Conduction: up to ); and is due to heating surfaces in contact with the !ody such as theatre ta!le or cold fluids. Evaporation contri!utes to 79"); and occurs from cleaning fluids5 skin5 respiratory5 !owel and wound surfaces. Respiratory 79"-; enhanced !y cooling effect of cold anaesthetic gases.

PHASE 1 5 PLATEAU
Once core temperature falls !elow the thermoregulatory threshold5 peripheral vasoconstriction increases and acts to limit the heat loss from the core. When core heat production e uals heat loss to the periphery5 core temperature reaches a plateau. This may not !e achieved in dia!etics with autonomic neuropathy and impaired vasoconstriction and also during com!ined general and regional anaesthesia.

PREVENTION AND MANAGEMENT

(igh risk patients include2 *hildren and elderly Pre9operative temperature <&,- * *om!ined general and regional anaesthesia =a>or or intermediate surgery Prolonged surgery Patients at risk of cardiovascular complications ASA &9) patients.

PRE6OPERATIVE
?eep the patient comforta!ly warm 8&,.)9&..) -*# !y providing sheets1warm clothes and !y maintaining higher am!ient temperature. /f temperature is !elow &,o* commence forced air warming unless immediate surgery is imperative.

INTRA6OPERATIVE MEASURES
=aintain am!ient temperature a!ove %"-*. *over the patient ade uately with either sheets or cotton roll or any other passive insulating material. This traps air under the insulation material and may prevent heat loss !y up to &-;. ATOTW "".. 5 Perioperative hypothermia5 prevention and management %-1"-1%--7 Page & of '

Active warming using forced air warmers such as the @:air huggerA illustrated !elow are devices that !low hot air into a !lanket on top of the patient. /t is more efficient than passive warming and prevents heat loss !oth !y convection and radiation. These warmers must !e used with the correct !lankets to prevent thermal in>ury.

Figure 2. Borced air warming !lanket

Figure 3. /ntravenous fluid warmer

Cse warmed irrigation fluids. *onnect a !lood and fluid warmer if large amounts of fluid and !lood product use are anticipated. Warm and humidify /nspired gases may !e warmed !y using a heat and moisture e4change device.

POST OPERATIVE7
*ontinue to monitor temperature and use appropriate measures to prevent further heat loss and keep the patient comforta!ly warm. /f the patientDs temperature is less than &, -* then commence forced air warming until thermally comforta!le.

REFERENCES7 "# Eational /nstitute of *linical F4cellence inadvertent hypothermia guideline5 we! address
http211www.nice.org.uk1nicemedia1pdf1*G,)Guidance.pdf. %# O4ford (and!ook of Anaesthesia5 Second edition5 Pages )%'9)%) &# www.frca.co.uk 9 We! link2 http211www.frca.co.uk1Section*ontents.asp4$sectionidH",.

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