HYPOTHERMIA

Dept of Anaesthesiology PSG IMS&R DR.P.JEYAKRISHNAN

Questions
Normal physiology ? Core body temperature ?

Monitoring Sites ?
Complications associated with hypothermia ? Prevention?

HYPOTHERMIA
Normal human body temperature in adults is maintained around 36.537.5 C (98100 F)

Hypothermia is defined as core body temperature below 35.0 C (95.0 F) It is subdivided into four different degrees: mild moderate severe profound 3235 C 2832 C 2028 C < 20 C (9095 F) (8290 F) (6882 F) (68 F)

Introduction
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 2% through warming the inhaled air Conduction (minimal)

Physiology of TEMPERATURE CONTROL

Hypothalamus modulates temperature information from skin, central and neural tissues Two types of thermostatic neurons are located in the hypothalamus

One 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 and increased perspiration. Decreased temperature causes conservation of heat by vasoconstriction 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.

Thermal compartments
core thermal compartment
highly perfused tissues
head, neck and the trunk evaluated in pulm.artery nasopharynx, tympanic membrane,dist.oesophagus rectum

Periph thermal compartment axilla Skin oral

bladder
Tympanic membrane ideal *

PHYSIOLOGIC EFFECTS OF HYPOTHERMIA

Metabolic effects decrease in O2consumption and C02 production Serum glucose levels are increased due to catecholamine release and a decrease in insulin production. Metabolic acidosis occurs resulting in an increase in potassium levels Central nervous system CBF is reduced, O2consumption is reduced MAC of volatile agents is decreased therefore a smaller concentration is needed and recovery may be delayed.

Blood decrease in plasma volume with an increase in viscosity Aggregation of platelets decreases their function
Respiratory system Shivering increases oxygen consumption 3-5 times pulse oximeter measurement becomes difficult & unreliable There is respiratory depression due to decreasing ventilatory drive. Hypoxic vasoconstriction is impaired resulting in an increase in ventilation/perfusion mismatch and hypoxaemia. The O2dissociation curve is shifted to the left decreasing oxygen delivery to the tissues.

PHYSIOLOGIC EFFECTS OF HYPOTHERMIA

Cardiovascular system 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 Urinary system Renal blood flow and GFR are decreased. Decreased Na reabsorption causes impairment of urine concentration leading to cold diuresis and hypovolaemia. Liver liver perfusion is diminished slowing down liver function and the metabolism of drugs

Why during anaesthesia?

Both general and regional anesthesia affect thermal homeostasis by blunting central thermoregulation defence mechanisms reducing the sympathetic tone with inhibition of peripheral vasoconstriction and consequent redistribution of body heat from core to the peripheral compartment Loss of shivering Exposure to a cold operating-room environment Operations involving open body cavities

Reasons for INTRA-OPERATIVE HEAT LOSS

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 also contributes to heat loss. Infants have an increased surface area to body mass ratio and therefore lose 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.

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.

When to measure core temperatures?

Core temperature usually decreases by 1.8*C in the first 40 minutes following induction of anaesthesia. Hypothermia at this stage results mainly from internal re-distribution of heat owing to anaesthetic-induced vasodilation in the peripheral tissues core temperature perturbations during the first 30 minutes of anaesthesia are difficult to interpret, and measurements are thus not required Core temperature should be monitored in patients given general anaesthesia for more than 30 minutes Core temperature should be measured in patients undergoing Major procedures under regional anaesthesia.

Complications of hypothermia
CVS higher prevalence of myocardial ischaemia and ventricular tachycardia tachycardia, hypertension, systemic vasoconstriction imbalance between myocardial oxygen supply and demand due to increased levels of circulating catecholamines Shivering after regional anaesthesia increases O2 demand can affect patients with borderline myocardical perfusion

Complications contd..
Blood impairing platelet function Impairing Clotting factor enzyme function This was seen frequently during colo-rectal and hip replacement surgery where blood transfusion is needed hypothermia + transfusion -> coagulopathy

Complications contd
Wound Infection Facilitates surgical wound infection by peripheral vasoconstriction with a significant reduction of subcutaneous oxygen tension directly impairs the immune function inhibiting T-cell mediated antibody production whose activity also depends on oxygen supply

Complications contd.
OTHER complications : Thermal discomfort for patients Prolonged action of drugs used eg: relaxants Delayed discharge from PACU May be more prone to DVT due to peripheral vasoconstriction & venous stasis

Prevention and Management of hypothermia

Prevention is better What can we do ? 1)Pre warming patients skin surface prior to surgery reduces temp gradient between core & peripheral compartment ie:minimizes redistributive hypothermia

2)By increasing the heat content in the peripheral compartment by administering vasodilators
Oral nifedipine ( 20 mg 12 hrs before surgery followed by other 10 mg 1 hr before inducing anesthesia) has been reported to significantly reduce redistributive hypothermia in surgical patients
Vassilieff N et al. Effect of premedication by nifedipine on intraoperative hypothermia. AnnFrancaises de Anesth et de Reanim 1992; 11: 484-7

Prevention and Management of hypothermia

Preventing radiation of heat by maintaining higher temp in OT ! Passive insulation surgical draping cotton blankets metallized plastic covers -efficiency of this system is directly proportional to the covered surface area

Prevention and Management of hypothermia

Active cutaneous warming systems forced-air warming devices are the most commonly used and efficient ones Provide heat by convection and prevent loss by radiation they increase core temperature by almost 0.75C/hour

Prevention and Management of hypothermia

Resistive heating blankets Circulating water mattresses Radiant warmers

Aural probe

Forced air warmer

Radiant warmer

Space blanket

resistive blanket

Prevention and Management of hypothermia

Internal Warming Systems Intravenous Fluid Warmers
*One litre of crystalloid solution or a unit of refrigerated blood decrease body temperature by about 0.25C

airway heating and humidification- HME filters

useful to preserve cilial function and prevent bronchospasm

OTHERS : peritoneal dialysis / A-v shunt cardiopulmonary bypass Effective but Cannot be routinely used

I.V Fluid warmers

Foley probe

skin probe

Oesophageal

rectal

Conclusion
Perioperative hypothermia seldom monitored is a frequent finding in surgical patient increasing the incidence of cardiovascular,hemorrhagic & infectious complications Hypothermia prevention is associated with significant reduction of surgery-related costs by reducing the incidence of complications and accelerating hospital discharge Children, Elderly & Hypothyroid patients are the most vulnerable and affect post-anesthesia outcomes

Take home points

Core temperature should be monitored in patients given GA for more than 30 minutes Core temperature should be measured in all patients undergoing Major procedures under RA best monitoring site should be chosen based on the characteristics and site of the surgical procedure Forced air is the most effective non-invasive warming method

References
Best Practice & Research Clinical Anaesthesiology Vol. 17, No. 4, pp. 569581, 2003 doi:10.1016/S1521-6896(03)00048-X HYPOTHERMIA AND TEMPERATURE REGULATION CONSIDERATIONS DURING ANESTHESIA by Marcos Daz, D.D.S. Clinical complications, monitoring and management ofperioperative mild hypothermia: anesthesiological features Marta Putzu, Andrea Casati, Marco Berti, Giovanni Pagliarini, Guido Fanelli

THANK YOU

Lets keep our patients warm & cozy !