REVIEW

A systematic review of randomised controlled trials of the effects of warmed irrigation uid on core body temperature during endoscopic surgeries
Yinghui Jin, Jinhui Tian, Mei Sun and Kehu Yang

Aims and objectives. The purpose of this systematic review was to establish whether warmed irrigation uid temperature could decrease the drop of body temperature and incidence of shivering and hypothermia. Background. Irrigation uid, which is used in large quantities during endoscopic surgeries at room temperature, is considered to be associated with hypothermia and shivering. It remains controversial whether using warmed irrigation uid to replace roomtemperature irrigation uid will decrease the drop of core body temperature and the occurrence of hypothermia. Design. A comprehensive search (computerised database searches, footnote chasing, citation chasing) was undertaken to identify all the randomised controlled trials that explored temperature of irrigation uid in endoscopic surgery. An approach involving meta-analysis was used. Method. We searched PubMed, EMBASE, Cochrane Library, SCI, China academic journals full-text databases, Chinese Biomedical Literature Database, Chinese scientic journals databases and Chinese Medical Association Journals for trials that meet the inclusion criteria. Study quality was assessed using standards recommended by Cochrane Library Handbook 5.0.1. Disagreement was resolved by consensus. Results. Thirteen randomised controlled trials including 686 patients were identied. The results showed that room-temperature irrigation uid caused a greater drop of core body temperature in patients, compared to warmed irrigation uid (p < 000001; I2 = 85%). The occurrence of shivering [odds ratio (OR) 513, 95% CI: 2951019, p < 000001; I2 = 0%] and hypothermia (OR 2201, 95% CI: 20319708, p = 001; I2 = 64%) in the groups having warmed irrigation uid were lower than the group of studies having room-temperature uid. Conclusions. In endoscopic surgeries, irrigation uid is recommended to be warmed to decrease the drop of core body temperature and the risk of perioperative shivering and hypothermia. Relevance to clinical practice. Warming irrigating uid should be considered standard practice in all endoscopic surgeries. Key words: endoscopic surgery, irrigation uid, systematic review, temperature
Accepted for publication: 31 July 2010

Authors: Yinghui Jin, RN, Nurse, The Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou and Nursing Department, Tianjin Medical University, Tianjin; Jinhui Tian, MD, Lecturer, The Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou; Mei Sun, RN, Professor, The Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou and Nursing Department, General Hospital of Tianjin

Medical University, Tianjin; Kehu Yang, MD, Professor, The Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou and The First Clinical College, Lanzhou University, Lanzhou, China Correspondence: Kehu Yang, Evidence-Based Medical Center of Lanzhou University, No. 199 Dong Gang West Road, Chengguan District, Lanzhou, Gansu, China. Telephone: +086 13893117077. E-mail: Kehuyangebm2009@126.com

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Introduction
Inadvertent perioperative hypothermia, dened as core body temperature 360 C, is a common complication induced by anaesthesia (Harper et al. 2008, p. 293). Torossian (2008, p. 659) indicates that major adverse outcomes from hypothermia start at 36 C. Several prospective, randomised trials have demonstrated several perioperative hypothermiainduced complications, mainly including: (1) increased the incidence of postoperative adverse myocardial events (Frank et al. 1997, p. 1130); (2) increased the incidence of surgical wound infection (Kurz et al. 1996, p. 1212); (3) prolonged duration of postanaesthetic recovery (Lenhardt et al. 1997, p. 1320); (4) increased thermal discomfort (Kurz et al. 1995, p. 363); (5) induced postoperative shivering which increases oxygen consumption (Just et al. 1992, p. 63) and (6) interference with the normal function of the clotting cascade and reduced ability of platelets (Michelson et al. 1994, p. 636) leading to intraoperative blood loss (Winkler et al. 2000, p. 981). The development of perioperative hypothermia is a common, serious and often troublesome reality faced by anaesthetists and perianaesthesia nurses. Factors contributing to hypothermia include low ambient temperature, length of anaesthesia and type of surgical procedure. Nowadays, endoscopic techniques are widely used in clinical diagnosis and medical treatment. In some endoscopic surgery, large quantities of irrigation uid are used at room temperature to dilate the vision space or operating eld and to clear blood and cut tissue. Several randomised controlled trials have attributed the drop in core body temperature or perioperative hypothermia to the use of room-temperature irrigation uid. Zaffagnini et al. also found that the use of room-temperature irrigation solution and the length of the surgical procedure were associated with a signicant reduction in keen-joint temperature after arthroscopic surgical procedures. Absorption of irrigating uid and associated haemodynamic changes played a role in the development of hypothermia. As blood circulating through the site of surgery is exposed to tissues that have been signicantly cooled by large volumes of roomtemperature irrigation and heat transfer from the blood to this site of surgery could lead to cooled blood being returned to the central circulation so causing a decrease in patient core body temperature (Zaffagnini et al. 1996, p. 199200). Because of the risks associated with hypothermia, active warming procedures are necessary to maintain normothermia in all patients undergoing anaesthesia or operation. Nevertheless, the status quo is not satisfactory. A survey performed in 801 European hospitals showed that temperature moni-

toring was performed in only 194% of the patients and only 385% of the patients were actively warmed (Torossian 2007, p. 668). Interventions to maintain patient body temperature in the operation room include covering the patients head and body, increasing ambient room temperature, warming intravenous and irrigating solutions and applying external warming devices. Among these methods, forced-air warming and circulating warm water garment have been proven to be effective and, when given in large amounts, warmed intravenous uid (Torossian 2008, p. 664). Nevertheless, the optimal irrigation uid temperature to be used during some endoscopic surgeries has been a source of controversy in published studies. The question is whether warm irrigating uid, compared with room-temperature irrigation uid, could prevent the occurrence of perioperative hypothermia during endoscopic operations. Many published reports have supported the nding of perioperative hypothermia associated with the use of room-temperature irrigation uid and the use of warmed irrigation uid to prevent the occurrence of perioperative hypothermia. However, Kelly et al. (2000, p. 249) showed that there was no statistically signicant difference in mean percent temperature decrease between the group receiving room-temperature uids and the group receiving warmed irrigation uid among patients undergoing knee arthroscopy and, moreover, the group receiving warmed irrigation solution tended to have a greater temperature drop than the control group. Jaffe et al. (2001, p. 1079) reported the temperature of irrigation uid is not a factor responsible for altering the core body temperature in patients undergoing transurethral resection of the prostate (TURP). Clearly, there are conicting views about whether irrigation uid temperature has an inuence on the core body temperature. In addition, there is another important issue. The view held by conventional surgery is that the higher the temperature, the greater the increase in blood loss. Walton and Rawstron (1981, p. 258) reported that using relatively cooled irrigation uid resulted in a small non-statistically signicant reduction in blood loss. Conversely, several studies showed warm irrigating uid did not increase blood loss compared to roomtemperature irrigation uid during TURP or transurethral resection of bladder tumour (TURBT) (Heathcote & Dyer 1986, p. 670, Zeng et al. 2008, p. 9, Ding et al. 2009, p. 12, Xie et al. 2009, p. 58). Therefore, in this systematic review, the researchers sought to identify the effect of warmed irrigation uid on body temperature and considered whether warmed irrigation uid increase blood loss, compared with room-temperature irrigation uid.

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Effects of warmed irrigation uid on core body temperature

Materials and methods

Search strategy
The search for relevant literature used several computerised databases, citation searching and footnote chasing. We searched the following databases from inception to June 2009: PubMed, EMBASE, Cochrane Library, SCI, China academic Journals Full-text Databases, Chinese Biomedical Literature Database, Chinese Scientic Journals Databases and Chinese Medical Association Journals using the following search terms: (endoscope* OR angioscope* OR arthroscope* OR bronchoscope* OR colposcope* OR culdoscope* OR cystoscope* OR fetoscope* OR embryoscope* OR hysteroscope* OR laparoscope* OR laryngoscope* OR mediastinoscope* OR neuroendoscope* OR thoracoscope* OR ureteroscope*) AND (irrigation uid* OR irrigating uid* OR irrigant uid* OR irrigation solution* OR irrigating solution* OR irrigant solution*) AND (temperature*). The search strategy incorporated MeSH terms with text words search. The detailed search strategy for each electronic database is available from the authors. We included unpublished trials retrieved from SIGLE (System for Information on Grey Literature) database, to reduce publication bias.

by contacting the original author of study for further information or by seeking an independent third opinion.

Assessment of risk of bias in included studies

Two authors evaluated the methodological quality of the studies for major potential sources of bias using criteria recommended in Cochrane Library Handbook 5.0.1 (Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1) (random sequence generation, allocation concealment, blinding of participants, incomplete outcome data, selective outcome reporting and other potential threats to validity). We did not use a scoring or grading system. Any disagreements were resolved through discussion or by contacting the study author to seek detailed information.

Data synthesis
We performed a test for heterogeneity of included studies using RevMan 5.0 software (Review Manager: Computer program). We expressed each study result as an odds ratio (OR) for dichotomous data or a weighted mean difference (WMD) or standard mean difference (SMD) for continuous data, with 95% condence intervals (CI). A xed effect model was used unless there was signicant heterogeneity as determined by chi-squared test (I2 > 50%), in which case results were investigated using a random effect model. When there were different designs, methods or methodological quality problems potentially interfering with the results of the review, sensitivity analysis was performed to seek any inuencing factors. We did not plan subgroup analysis. When data could not be extracted to calculate total effect, any available data would be reported descriptively.

Selection of studies
There were 266 studies identied from electronic databases and other sources and 20 from additional citation searching and footnote chasing. Two authors independently reviewed the abstracts of all 266 studies with the following inclusion criteria: (1) type of study was randomised controlled trial; (2) participants should have any kind endoscopic surgery and there were no exclusions on the basis of type of anaesthesia, disease, age or gender; (3) type of interventions was roomtemperature irrigation uid versus warmed irrigation uid; we dened the temperature of warmed irrigation uid as equal or near to body temperature; (4) studies must measure at least one of the outcome variables: the incidence of perioperative hypothermia (360 C) or shivering, body temperature drop, time to regain initial temperature, blood loss and (5) We limited language to English or Chinese.

Results
Of 266 studies screened, 18 studies were retrieved for indepth consideration in this study. Five studies were excluded for the following reasons: (1) one study clearly had the wrong data (Yi et al. 2005, p. 10) and we failed to contact the author and (2) four studies (Heathcote & Dyer 1986, Harioka et al. 1988, Mirza et al. 2007, Board & Srinivasan 2008) were non-randomised controlled trials. Finally, 13 eligible trials (Monga et al. 1996, Pit et al. 1996, Moore et al. 1997, Kelly et al. 2000, Jaffe et al. 2001, Chen & Tong 2002, Fu et al. 2004, Sun et al. 2006, Okeke 2007, Zeng et al. 2008, Ding et al. 2009, Kim et al. 2009, Xie et al. 2009) involving 686 patients with an age range from
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Data extraction
Data were extracted independently by two authors using a standard data extraction checklist. Data included characteristics of included studies (methods, participants, interventions, outcomes). Any disagreements were resolved by discussion or

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266 identified from electronic databases and other sources 60 citations excluded because duplicate 206 citations selected for further review 20 added from searching additional citations and footnotes 208 citations excluded after first screen because subject and intervention not related to our review or non-English or non-Chinese language 18 full-text articles screened for eligibility 5 articles excluded after full text screen, reason for exclusion: 1 had clearly wrong data (Yi et al. 2005, p. 10) 4 non-RCT (Heathcote & Dyer 1986, Harioka et al. 1988, Mirza et al. 2007, Board et al. 2008) 13 articles included in systematic review

The incidence of perioperative shivering

Information on incidence of shivering was available for ve studies (312 patients). There were no important heterogeneity among these studies (p = 092, I2 = 0%). The incidence of shivering in group receiving room-temperature uid was higher than in group receiving warmed uid (OR = 513, 95% CI 2951019, p < 000001) (Fig. 3).

The incidence of perioperative hypothermia

Three studies (103 patients) reported the incidence of hypothermia. There was substantial heterogeneity between three studies (p = 006, I2 = 64%). Compared with roomtemperature group, the warmed irrigation uid group have a lower incidence of hypothermia (OR = 2201, 95% CI 203 19708, p = 001) (Fig. 4). Moore et al.s (1997) trial was performed on 35 women undergoing laparoscopic surgery. Laparoscopic surgery involves an element which is different from arthroscopic surgery or TURP. Large volumes of gas, most commonly carbon dioxide, are used to insufate the peritoneal cavity in laparoscopic surgery. The cooling effect of insufation gas is a cause of hypothermia. A decrease of 03 degrees in core temperature was observed for each 50 l of carbon dioxide delivered (Ott 1991). The total CO2 used in Moore et al.s trial is 79 (SD 16) (L) and 82 (SD13) (L), respectively, in two groups. This may explain the high incidence of hypothermia in both groups in this trial. Therefore, we excluded this study to perform sensitivity analysis. Figure 5 showed that after sensitivity analysis, heterogeneity disappeared (p = 078, I2 = 0%). Signicantly more patients developed hypothermia following the use of roomtemperature irrigation uid than in the group having warmed irrigation uid (OR = 5806, 95% CI 133825198, p < 000001).

Figure 1 Paper review ow chart.

28952 years were selected. The endoscopic procedures used included transurethral resection of the prostate (TURP); hysteroscopic electric resection of endometrium (TCRE); minimally invasive percutaneous nephrolithotomy (MPCNL); laparoscopic surgery and arthroscopic surgery. The type of anaesthesia was spinal, general or epidural (Fig. 1).

Characteristics of included trials and methodological quality

We identied 13 randomised controlled trials. Reporting of methodological details was not satisfactory. All of these studies were stated to be randomised, but randomisation methods are not fully described in 10 of the studies. Allocation concealment was unclear in all studies. Three of the trials (Moore et al. 1997, p. 599, Kelly et al. 2000, p. 248, Kim et al. 2009, p. 25) gave information about the reasons for incomplete outcome (Tables 13).

Intraoperative blood loss

Figure 6 showed that there was no heterogeneity between trials (p = 045, I2 = 0%). Warmed irrigation uid decreases blood loss less than room-temperature irrigation uid (WMD = 1554 ml, 95% CI 6672441, p = 00006).

Perioperative body temperature drop

Figure 2 showed 10 studies reporting body temperature drop involving 533 patients. Because of the substantial heterogeneity (p < 000001, I2 = 87%), we omitted the pooled estimate and just performed a narrative synthesis. As shown in Fig. 2, there was consistency in the direction of effect which illustrated that room-temperature irrigation uid could induce more decrease in mean body temperature than warmed irrigation uid.

Time taken to regain initial temperature

Only one study (Pit et al. 1996) reported time taken to regain initial temperature. In this study, two sites (rectal and oral) were used to measure temperature. The result was only just signicant (rectal, p = 004, t-test) and no signicant different

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Table 1 Characteristics of the trials included in the review The sites of temperature measurement Oral Rectal and oral

Study: authors, years, country Type of surgery TURP TURP Laparoscopic surgery 9/11 355 78 378 116 2075/40 Spinal anaesthesia 16/13 30 2 35 1 2022/39 31/28 72 7 72 8 206/375 14/14 675 84 734 86 2224/3537 N C/T

Ages (years) C/T

Temperature (C) of the C/T

Type of anaesthesia

Heating equipment Fluid warmer or incubator Fluid heater Pressurised uid warming system Warming cabinet

Monga et al. (1996), USA

Pit et al. (1996), the Netherlands Moore et al. (1997), USA

Spinal/general anaesthesia Spinal anaesthesia General anaesthesia

Kelly et al. (2000), Philippines 27/29 21/33 1922/368375 30/30 31/31 30/34 65 5 761 191 4640 931 40/40 30/30 33/33 28/28 23/23 458 133 759 202 4617 1088 460 21 65 30 504 145 67 68 6 2124/3738 21/37 27 5/38 23 1/35 1 2427/37 2224/3638 2022/3739 705 688 715 82 709 80

Oesophageal tympanic membrane Tympanic membrane Incubator Hotline heater Incubator Incubator Incubator Fluid heater

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 305316 Knee arthroscopy surgery TURP TURP TUPR TURP TURP MPCNL TCRE TURP Shoulder arthroscopy surgery Tympanic membrane Rectal Epidural/general anaesthesia Epidural anaesthesia Epidural/spinal anaesthesia Epidural anaesthesia Intravenous anaesthesia Epidural anaesthesia General anaesthesia Rectal Oral Rectal Rectal Oesophageal

Jaffe et al. (2001), USA

Chen & Tong (2002), China

Fu et al. (2004), China Sun et al. (2006), China

Okeke (2007), Nigeria Zeng et al. (2008), China Ding et al. (2009), China Xie et al. (2009), China Kim et al. (2009), Korea

Effects of warmed irrigation uid on core body temperature

C, control group (room-temperature irrigation uid); T, treated group (warmed irrigation uid); TURP, transurethral resection of the prostate; TCRE, hysteroscopic electric resection of endometrium; MPCNL, minimally invasive percutaneous nephrolithotomy.

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310 Surgical time (min) C/I 66 22 77 25 Total irrigating uid (l) C/I Outcomes 96 8 456 201 1022 306 58 75 11 78 70 9 23 000 (ml) 20 000 (ml) 33 000 (ml) 443 226 968 279 117 107 17 333 1226 (ml) 118 110 17 596 1013 (ml) 90 10 1481 231 (ml) 1264 231 (ml) 3090 51 22 49 17 203 7 30120 23 500 (ml) 25 000 (ml) 222 3 483 210 376 120 467 190 326 152 4020 1130 (ml) 39 800 1320 (ml) 68 10 911 324 945 219 71 9 20 000 (ml) 103 43 98 32 The incidence of hypothermia; body temperature Body temperature; time to regain initial time; haemoglobin; resected weight; the patient numbers of feeling cold The incidence of hypothermia; body temperature below baseline; total CO2 used Mean percent body temperature decrease The incidence of decreased temperature; body temperature; resected weight Body temperature; the incidence of shivering Body temperature; the incidence of shivering; blood pressure; the patient numbers of feeling cold The incidence of shivering; blood pressure; resected weight; heart rate The incidence of shivering; body temperature below baseline; the number of feeling cold: the mean time of postoperative hospital stay Body temperature; blood loss Blood loss; amount of liquid absorption; serum sodium, potassium, urea nitrogen; anion gap; temperature; resected weight Body temperature; blood loss; blood pressure; heart rate Haemoglobin; temperature; hypothermia; shivering; postoperative pain (VAS); postoperative weight gain

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Table 2 Characteristics of the trials included in the review

Study: authors, years, country

Monga et al. (1996), USA Pit et al. (1996), the Netherlands

Moore et al. (1997), USA

Kelly et al. 2000, Philippines Jaffe et al. (2001), USA

Chen & Tong (2002), China Fu et al. (2004), China

Sun et al. (2006), China

Okeke (2007), Nigeria

Zeng et al. (2008), China Ding et al. (2009), China

Xie et al. (2009), China

Kim et al. (2009), Korea

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C, control group (room-temperature irrigation uid); I, intervention group (warmed-temperature irrigation uid).

Review Table 3 Methodological quality of included trials

Effects of warmed irrigation uid on core body temperature

Study: authors, years, country Monga et al. (1996), USA Pit et al. (1996), the Netherlands Moore et al. (1997), USA Kelly et al. (2000), Philippines Jaffe et al. (2001), USA Chen & Tong (2002), China Fu et al. (2004), China Sun et al. (2006), China Okeke (2007), Nigeria Zeng et al. (2008), China Ding et al. (2009), China Xie et al. (2009), China Kim et al. (2009), Korea

Sequence generation Unclear Unclear Random numbers table Random numbers table Unclear Unclear Unclear Unclear Picking a ballot Unclear Unclear Random number table Unclear

Allocation concealment Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear

Blinding Single-blind Single-blind Unclear Unclear Double-blind Unclear Unclear Unclear Unclear Unclear Unclear Unclear Observer

Incomplete outcomes data No No Yes Yes No No No No No No No No Yes

Selective outcome reporting Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear

Other potential threats to validity Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear

Figure 2 Perioperative body temperature drop for room-temperature group and warmed group; standard mean difference with 95% condence interval (CI).

Study or subgroup Chen 2002 Fu 2004 Jaffe 2001 Kim 2009 Monga 1996 Moore 1997 Okeke 2007 Pit 1996 Xie 2009 Zeng 2008

Room-temperature Mean SD Total 151 048 30 16 0416 31 27 002 075 086 02 23 095 047 14 16 17 02 098 056 40 171 11 30 15 28 036 071 045 30

Warmed Mean SD 041 045 08 0357 01 063 028 02 042 064 1 02 042 021 074 06 08 034 014 03

Total Weight 30 31 29 23 14 13 40 26 28 30

Std. Mean difference IV, Fixed, 95% CI 233 [167, 300] 204 [142, 266] 011 [064, 041] 285 [201, 369] 092 [013, 170] 340 [221, 459] 131 [083, 180] 106 [050, 162] 197 [132, 262] 147 [090, 205] 4

Std. Mean difference IV, Fixed, 95% CI

Study or subgroup Chen 2002 Fu 2004 Kim 2009 Okeke 2007 Sun 2006

Warmed Room-temperature Total Events Total Weight Events 6 9 5 13 12 30 31 23 40 30 2 2 0 3 5 30 31 23 40 34 194% 172% 47% 246% 341%

Odds ratio M-H, Fixed, 95% CI 350 [065, 1898] 593 [116, 3025] 1397 [073, 26923] 594 [154, 2290] 387 [117, 1281] 513 [259, 1019]

Odds ratio M-H, Fixed, 95% CI

Figure 3 The incidence of perioperative shivering for room-temperature group and warmed group; odds ratio (OR) with 95% CI.

154 Total (95% CI) 158 1000% Total events 45 12 Heterogeneity: c 2 = 093, df = 4 (p = 092); l 2 = 0% Test for overall effect Z = 468 (p < 000001)

0001

01

10

1000

Study or subgroup Kim 2009 Monga 1996 Moore 1997

Odds ratio Warmed Room-temperature Events Total Events Total Weight M-H, Random, 95% CI 21 13 15 23 14 16 53 49 18 0001 4 2 12 23 14 13 394% 319% 286% 4988 [818, 30393] 7800 [624, 97471] 125 [007, 2213] 2001 [203, 19708]

Odds ratio M-H, Random, 95% CI

Figure 4 The incidence of perioperative hypothermia for room-temperature group and warmed group; OR with 95% CI.

Total (95% CI) Total events

50 1000%

Heterogeneity: t 2 = 260; c 2 = 556, df = 2 (p = 006); I 2 = 64% Test for overall effect: Z = 257 (p = 001)

01

10

1000

Study or subgroup Kim 2009 Monga 1996

Room-temperature Warmed Total Events Total Events 21 13 23 14 37 34 6 4 2 23 14

Weight 709% 291%

Odds ratio M-H, Fixed, 95% CI 4988 [818, 30393] 7800 [624, 97471] 5806 [1338, 25198]

Odds ratio M-H, Fixed, 95% CI

Figure 5 Sensitivity analysis of the incidence of perioperative hypothermia for room-temperature group and warmed group; OR with 95% CI.

Total (95% CI) Total events

37 1000%

Heterogeneity: c 2 = 008, df = 1 (p = 078); I 2 = 0% Test for overall effect: Z = 542 (p < 000001)

0001

01

10

1000

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Room-temperature Warmed Study or subgroup Mean SD Total Mean SD Total Weight Ding 2009 Xie 2009 Zeng 2008 Total (95% CI) 428 262 5233 273 33 456 291 413 33 28 Mean difference IV, Fixed, 95% CI Mean difference IV, Fixed, 95% CI

422 28 235 254 30 91

3883 969 30

04% 2800 [16414, 10814] 164% 2700 [513, 4887] 831% 1350 [377, 2323]

91 1000% 1554 [667, 2441] 50 25 0 25 50

Heterogeneity: c 2 =162, df = 2 (p = 045); I 2 = 0% Test for overall effect: Z = 343 (p = 00006)

Figure 6 Intraoperative blood loss for room-temperature group and warmed group; weight mean difference with 95% CI.

(oral, p = 007, t-test) between the population who received room-temperature irrigating uid and those who received warmed irrigating uid. The available evidence did not show warmed irrigation uid can decrease the time to regain initial temperature.

Discussion
In this meta-analysis, although the quality of the studies in this review is not satisfactory, it is possible to draw the conclusion that during endoscopic surgery, warmed irrigation uid can decrease heat loss, shivering and hypothermia and it also decreases the blood loss. Therefore, the use of warmed irrigation uid is of benet during endoscopic surgery. There was heterogeneity between 10 studies about body temperature drop. Differences in the temperature and volume of irrigating uids (Tables 1 and 2) or differences in supplementary heating methods used for the patients could have affected outcomes and resulted in heterogeneity. There are two studies that used warming mattress or blankets for every patient in both control group and treated group in addition to warmed irrigation uid for treated group. Jaffe et al. (2001) reported that the patients were covered with a gown and a warm blanket (45 C) from their neck to the level of their umbilicus to help protect against heat loss during the procedure. Moore et al.s trial (1997, p. 599) reported that the patient lay on a heating blanket set at 378 C. The fact that they actively warmed patients during operation could interfere with the effect of warmed irrigation uid. However, from the forest plot, we can see that the majority of the studies did show that using warmed irrigating uid decreased body temperature drop. It is worth noting that Jaffe et al. (2001) and Kelly et al. (2000, p. 249) contest the conclusion that warm irrigating uid can maintain a higher body temperature. Kelly et al. reported that the group receiving warmed irrigating solution tended to have a greater decline in temperature than the control group (although there was no statistically signicant difference in mean percent temperature decrease from baseline between groups). The authors explain that this trend may be because of heat loss associated within knee joint tissues. Subsequent infusion of warm irrigation solution into knee
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joints may actually increase heat loss by exacerbating or extending the duration of vasodilatation associated with spinal-induced sympathectomy. The sample size of this study is small (n = 20), so further study is needed to verify this result. Body temperature decrease in this study is reported in percent (%) temperature decrease from baseline which is different with other studies and could not be used for calculating combined effect size. Jaffe et al. also suggest that irrigation uid temperature is not a factor responsible for altering the core body temperature in patients undergoing TURP, they also reported that 20 (357%) from a total 56 patients demonstrated an increase in core body temperatures after TURP. This result was neither expected nor reported by the other included studies. A factor that may have contributed to the observed elevation in body temperature is the rigorous use of the warming blankets (45 C) both intraoperatively and postoperatively to assist the patients in maintaining their core body temperature. Two other aspects of the study design warrant special attention: 1 Core temperature is the best indicator of body temperature. Therefore, all non-core sites need to be judged by their ability to accurately access core temperature (Kurz 2008, p. 52). The included studies used different methods of temperature measurement. Most studies claimed that their methods or sites of temperature measurement reect core body temperature. So far, there is not agreement about the most accurate method of core body temperature monitoring during anaesthesia. The invasive measurement in the pulmonary artery is regarded as the gold standard for core temperature determination (Kurz 2008, p. 52). A systematic review by Hooper and Andrews (2006, p. 33) reported that infrared ear temperature measurement can not be recommended for perioperative use, because of its poor performance. Oral temperature has proved an accurate surrogate for core temperature, although it provides a value below actual core body temperature of around 02 03 C (Hooper & Andrews 2006, p. 31). The result of a review (Kurz 2008, p. 53) also suggested that tympanic infrared thermometers, infrared temporal artery measurements, peripheral skin temperatures are not recommended. ASPANs clinical practice guideline stated available near-

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Effects of warmed irrigation uid on core body temperature

core measures (e.g., oral, bladder, rectal, temporal artery, tympanic membrane) must be relied on to evaluate thermal balance across much of the perianaesthesia/perioperative period. Unfortunately, each near-core measure has limitations in the ability to reect core temperature. Overall, the research on perianaesthesia temperature measurement is weak because of lack of controls, insufcient statistical analysis and lack of replication (Hooper et al. 2009, p. 275). So, further research is needed to develop non-invasive and unied temperature monitoring devices for core temperature during anaesthesia. 2 In included studies, patients who underwent transurethral resection were generally older. Harioka et al. (1988, p. 328) suggest that older people tend to exhibit more pronounced and prolonged hypothermia. However, Pit et al. (1996, p. 100) reported that there was no relationship between the degree of cooling and the age or body weight of the patients. Kim et al. (2009, p. 27) also claimed that core body temperature did not correlate with the patients age in the warmed uid group. Further research is needed to solve this controversial issue. From Fig. 2, we nd it is clear that core body temperature of both control and treated groups in all the above-mentioned studies decreased throughout the intraoperative period. This means that the use of warmed irrigation uid can decrease, but not eliminate, temperature drop. Continued heat loss in the group of patients receiving warmed irrigation uid may have been augmented by local vasodilatation of vascular beds because of the infusion of warmed irrigation uid and transfer of heat from blood to surrounding tissues and to the environment. The clinical implications of even a small degree of hypothermia may be signicant. Most of studies devised some methods to provide warmed irrigating uid at a constant temperature with minimal interference, then ensure the effectiveness of the trials. The temperature of warmed irrigation uid in studies reviewed ranged from 3340 C, so it would not cause burn injure. There were not any signicant negative side-effects in all reports of included studies.

problems encountered were lack of allocation concealment, ITT analysis and partial use of blinding. These problems might be the source of bias which threatens the validity of the reported results. Two of the included studies (Fu et al. 2004, p. 44, Okeke 2007) measured subjective indicators like feeling cold. Although one study reported blinding of patients, it is desirable for subjective indicators to have blinding of participants and outcome assessors. 3 Our search strategy may have missed some relevant studies by only including English and Chinese publications. However, we did not nd related literatures in languages other than English and Chinese. So the language aspect of the search strategy may not have impacted the validity of our results. In view of these limitations, we applied strict inclusion criteria to our study, and we also systematically explored the issue of heterogeneity by use of sensitivity analysis. These methodological strengths have therefore enhanced the validity and applicability of our ndings. Prospective, large sample size, well-designed, double-blind RCTs are needed to verify these ndings. 4 The limited studies precluded meaningful subgroup analysis (based on variations in the amount of uid or different degree of warming of irrigating uid), which is important, given the heterogeneity of the study.

Conclusions and relevance to clinical practice

Although there were some limitations in the above-mentioned included studies, the result does indicate that the use of warmed irrigating uid is a reasonable means of decreasing heat loss and the risk of perioperative shivering and hypothermia, which suggests nurses should actively use warm uids for irrigation during endoscopic surgeries. However, the decision on whether or not to warm irrigation uids is made by surgeons, not anaesthetists or intensive care specialists in most of countries. So, it is critical to raise awareness about the importance of intraoperative temperature management in all surgical specialists. Nurses and other surgical specialities should unite and reach a consensus on implementing warming irrigating and other effective warming methods to maintain normothermia in patients throughout endoscopic surgeries.

Limitations of this review

1 One limitation of this review is the low number of eligible studies, especially those reporting the incidence of hypothermia and the time to regain initial temperature as outcomes. In addition, small sample size limits the applicability of several study ndings. Some results may not be shown because of small sample size. 2 Methodological quality of included studies was low. It may lead to some selection and performance bias. The

Acknowledgements
The authors gratefully acknowledge help by Jean Glover and Weijie Gao of the Nursing Department of Tianjin Medical University for their aid in revising the paper.
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Contributions
Study design: KHY, MS; data collection and analysis: YHJ, MS and manuscript preparation: YHJ, JHT.

Conict of interest
We declared that we had no nancial and personal relationships with other people or organisations that can inappropriately inuence our work.

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