Dr John Andrzejowski Royal Hallamshire Hospital Sheffield · Neither transient nor persistent...
Transcript of Dr John Andrzejowski Royal Hallamshire Hospital Sheffield · Neither transient nor persistent...
Dr John Andrzejowski
Royal Hallamshire Hospital
Sheffield
316 hospitals GA: temp monitor in 25% (Naso-pharyng)
43% actively warmed
Regional: temp monitor in 6% (tympanic)
28% warmed
A. Torossian & TEMMP study group. EJA (2007), 24:668-675
If you don't measure temperature you will never find hypothermia!
Why IPH occurs
Risk factors
NICE guidelines
Sensible implementation
INADVERTENT PERIOPERATIVE HYPOTHERMIA (IPH): < 36OC.
1. Day Case unit PACU (94pts)
1. 40% were < 36OC
2. 8% <35.5OC. 2. Major Surgery
1. 44% of patients <36°C intraop
2. 35% of patients <36°C in PACU. 3. Main theatres PACU: ORMIS
1. 7,631 out of 26,435 were < 36OC =29%
Hoyle & Andrzejowski JODS 2008;18(3):76-8
SENSORS:
Skin
Brain
Spinal cord
Deep tissues
Hypothalamus HYPOTHALAMUS:
SET POINT 37.1
36.7
Active vasodilation
Sweating
Behaviour
TR Vasoconstriction
Shivering
Behaviour
NS Thermogenesis
Inter-threshold
range
Direct vasodilatation Central effects on thermoregulation
Vasoconstriction thresholds fall
Shivering inhibited Heat Loss > production
Radiation
Convection; air currents – v impt.
Conduction; cool bed & IV fluids
Evaporation; up to 25%
Sessler: Anesthesiology 2000;92(2):578
Sessler: Anesthesiology 2000; 92(2):578
Redistribution
Ht loss > production
Plateau
Ambient temp
Surgery; length & type
Body morphology
ASA
Type of anaesthetic
Age
Premeds
90% of heat lost by radiation & convection Radiation; ≈ (temp diff)4
Keep theatre @ 21OC until covered Especially for short
cases
Major cases are higher risk
open abdomens
lots of washout etc
xtra fluids Don’t forget short cases...
NICE says warm any lasting over 30minutes
High risk need warming from start.
Kurz et al. Anesth Analg 1995; 80: 562-7
% body fat
< Favours higher ASA ..... Favours ASA 1 >
Not just GAs Regionals:
often feel warm!
Central effect
Vasodilatation; unabated heat loss
TR Thresholds affected above block
Change in afferent input?
Cold sensation not triggered
Combined regional & GA at most risk
Vasoconstriction & shivering thresholds lower younger patients shiver @ 36.1°C
80yr old may not shiver until temp < 35.2°C
Vasocontriction less efficient
Lower metabolic rate produce heat more slowly.
Recovery from even mild hypothermia prolonged
Definitely at greater risk if allowed to get cold...
< Favours control ..... Favours Midazolam >
Ambient temp
Surgery; length & type
Body morphology
ASA
Type of anaesthetic
Age
Premeds
Wound infections
Coagulopathy
Prolonged drug action
Myocardial morbidity
Recovery times prolonged
Shivering
400 patients colon surgery Ambient or 40°C blower Prophylactic antibiotics Outcomes: Post op wound infection
Feeding,
Length of stay
Stopped after 200 patients
Kurz A et al. NEJM 1996;334(19):1209-15
NEJM 1996;334(19):1209-15
• Wound infection α s/c O2 tension for 4 hours after bacterial exposure.
• IPH → ↓tissue blood flow & ↓ s/c O2
• Direct impairment of (T cell & Neutrophil) immune function
• ↓ synthesis of collagen
Platelet function impaired
Local phenomenon
↓release of thromboxane A2
Fibrinolytic activity unaffected
Clot formation affected rather than ↑lysis
Standard coag tests unchanged @ 37°C
Prolonged when performed @ patient temp
Intrinsic & extrinsic probably affected
N=60 Normothermic
36.6 0C P
Intraoperative blood loss
1.2 +/- 0.5 L <0.001
Transfusion requirement
1 unit <0.05
Schmied H et al. Lancet 1996; 347: 289-92
Schmied H et al. Lancet 1996; 347: 289-92
N=60 Normothermic
36.6 0C Hypothermic
-1.6 0C P
Intraoperative blood loss
1.2 +/- 0.5 L 1.7 +/- 0.3 L <0.001
Transfusion requirement
1 unit 8 units in 7 patients
<0.05
618
488
0
100
200
300
400
500
600
700
Conventional
36.1C
Aggressive 36.5C
Blo
od
lo
ss (
mls
)
86
40
80
29
0
10
20
30
40
50
60
70
80
90
100
MAP mmHg Number transfused
Conventional 36.1C
Aggressive 36.5C
Winkler M. Anesth Analg. 2000;91:978-84
0
10
20
30
40
50
60
70
80
Vecuronium -2 deg C Atracurium -3 deg C
du
ratio
n (
min
s)
Normothermia
Hypothermia
Volatiles: • Hypothermia ↓MAC
• More soluble; ↑ body content –
• longer recovery
[propofol] ↑ 30% @ 3
C hypoth. • ↓ Hepatic metabolism
[fentanyl] ↑ ~ 5% per
C hypothermia
Wound infections
Coagulopathy
Prolonged drug action
Myocardial morbidity
Recovery times prolonged
Shivering
Frank SM et al Anesthesiology 1995; 82:83–93
300 pts: intra vs post-op • ECG events
• Ischaemia, arrhythmia
• Morbid cardiac events
• Unstable angina
• Cardiac arrest
• Infarction 0
5
10
15
20
25
ECG event Morbid cardiac
event
Overall
Postoperative cardiac outcomes
%
Normothermia 36.7 0 C
Hypothermia 34.5 0 C
Frank et al JAMA 1997; 277:1127-34
< Favours hypothermia.... Favours normothermia >
NEJM 1996;334(19):1209-15
50,689 patients between 2000 and 2008 first 24 h in ICU after elective non-cardiac surgery.
23,165 (46%) were hypothermic transient in 22,810 (45%)
persistent in 608 (1.2%)
Neither transient nor persistent hypothermia
was independently associated with increased hospital mortality or length of stay.
Karalapillai et al. Anaesthesia 2013, 68, 605–611
• Cold sensation ‘worse than surgical pain’.
• Aggravates postoperative pain
• Impedes monitoring
• ↑ intraocular & IC pressures
• Can occur @ normothermia
• Brain & S Cord recover at diff rates • SV > IPPV • Males > females
• Body needs help • Warming prn • Phamacological: NNT 2
• pethidine 25 mg
• clonidine 150 mcg
• doxapram 100 mg
Kranke. Anesth Analg. 2002;94(2):453-60
Preventing perioperative
hypothermia
2008 NICE clinical guideline 65
Implementing NICE guidance
on
Inadvertant Perioperative Hypothermia
Patients (& families and carers) should be informed before and on admission that:
• staying warm before surgery will lower the risk of postoperative complications
• the hospital environment may be colder than their own home
• they should bring additional clothing to help them keep comfortably warm
• they should tell staff if they feel cold at any time during their hospital stay.
Each patient should be assessed for their risk of IPH and potential adverse consequences before transfer to theatre.
1 hour before
When using any device to measure patient temperature, healthcare professionals should:
be aware of, and carry out, any adjustments that need to be made in order to obtain an estimate of core temperature from that recorded at the site of measurement
be aware of any such adjustments that are made automatically by the device used.
We all use different devices...
METOPIC REGION. FEMALES COLDER THAN MALES!
SUPERFICIAL TEMPORAL & POST AURICULAR
Physiological measurement 2008; 29: 341–8
Langham & Sessler. Anesthesiology 2009;111:90-6
• Electronic oral temperatures best for postop use. • Axillary temperature is a reasonable substitute. • Temporal artery thermometry (TAT) seemed
accurate but additional validation prudent before adopting TAT for routine postop use
• May miss hypothermia & hyperthermia.
• Intraop temperatures more accurate than
postop: more reliable for performance measures.
If core temperature is < 36.0°C in the hour before they leave the ward or emergency department: FAW should be started on the
ward or in A&E (except for clinical urgency)
FAW should be maintained intraoperatively
If started early, lists should not be affected
• 421 pts having short, ‘clean’ surgery
• breast, VV, hernias: 50 mins av • Standard, local or systemic warming
• Non contact radiant heat dressing • Reviewed @ 2 & 6 weeks post op. • Wound infection • ASEPSIS scoring system • Antibiotic use
Melling AC et al. Lancet 2001; 358: 876-880
Warmed n=277 Standard n=139
Post op ABs 7% 16%
Wound inf 5% 14%
ASEPSIS > 10 7% 17%
NNT 10 local
15 systemic
Melling AC et al. Lancet 2001; 358: 876-880
BUT....no perioperative temps were recorded!
• 68 adults - spinal surgery
• 37 controls
• 31 prewarmed @ 70 mins
• @ 38
C, using Bair Paws®
• Routine FAW intraop.
35.6
35.8
36.0
36.2
36.4
36.6
36.8
37.0
Induction 20 40 60 80 100 120 140 160
Time (minutes)
Tem
pera
ture
(OC
)
Non Prewarmed
Prewarmed
Andrzejowski et al. BJA; Nov 2008
Core temp 0.3OC ↑at 40, 60 and 80 minutes
(p < 0.05). Andrzejowski et al BJA 2008: 101; 627-31
Non warmed overall = 57%
Prewarmed overall = 32%
0
5
10
15
20
25
30
35
40
45
50
Indu
ction
20 40 60 80 100
120
140
160
Time (minutes)
% p
ati
en
ts h
yp
oth
erm
ic (
<36.0
°C)
Prewarmed
Nonprewarmed
Non warmed overall = 57%
Prewarmed overall = 32%
Horn et al. Anaesthesia 2012; 67: 612-617,
Non prewarmed
10 minutes
20/30 minutes
• Induction of anaesthesia should not begin unless the patient’s temperature is
> 36.0°C
• The patient’s temperature should be measured and documented before induction of anaesthesia & every 30 mins
Diff to cook a patient in < 1hour!!
? temp probes for
> 60 mins
Most patients!
Leave the blanket on!
Active warming (FAW) from induction for
anaesthesia > 30 mins &
IPH ‘high risk’ patients having anaesthesia < 30
mins
If any two of the following apply, patients are at higher risk of IPH.
ASA grade II to V
preoperative temperature < 36.0°C
undergoing combined GA and regional
undergoing major or intermediate surgery
at risk of cardiovascular complications.
Sessler DI. Anesth Clin North Am 1994; 12:425-56
∆ in mean body
temperature 0C
Plug in & switch on
pre-induction
Sceptical and skint!
Intravenous fluids (500 ml or more) and blood products should be warmed to
37
C using a fluid warming device
Group Room
Temperature
Warming Cabinet
+
Inline warmer
Chi
squared
% of patients with temp
<36 C at any point
intra op
68%
47%
0.085
% of patients with temp
<36 C on arrival
in PACU
33%
14%
0.03 *
Andrzejowski et al. Anaesthesia. 2010: 65; 942
Warming Cabinet
Room Temperature
In-line warmer
Andrzejowski et al. Anaesthesia. 2010: 65; 942
* p=0.006 (warming cabinet vs
room temperature)
• Temperature should be measured and documented on admission to PACU and then every 15 minutes...
• Ward transfer only if temperature > 36.0°C. • If temperature is < 36.0°C: active FAW
• Until discharged from PACU or until comfortably warm
Warm blankets are placebo!
Conclusions:
• Hypothermia can have serious sequelae
• Keep patients warm preop
• Consider prewarming.
• Measure temperature
• Short cases & regionals get cold
• Warm hard & early
• Warm all fluids
Total Studied
n < 360C %
Prewarming study (BJA) 37 3 8%
Snapshot RHH (July 2008!) 164 11 7%
Fluid warming study 61 7 11%
Circadian rhythm... Elderly have less variation