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International Journal of Nursing Studies 51 (2014) 181189

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International Journal of Nursing Studies


journal homepage: www.elsevier.com/ijns

Warming with an underbody warming system reduces


intraoperative hypothermia in patients undergoing
laparoscopic gastrointestinal surgery: A randomized
controlled study
Ying Pu a, Gang Cen b,1, Jing Sun c, Jin Gong a, Ying Zhang a, Min Zhang a,
Xia Wu a, Junjie Zhang d, Zhengjun Qiu b,**, Fang Fang a,*
a

Department of Nursing, Afliated First Peoples Hospital, Shanghai Jiao Tong University, Shanghai 200080, PR China
Department of General Surgery, Afliated First Peoples Hospital, Shanghai Jiao Tong University, Shanghai 200080, PR China
c
Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, PR China
d
Department of Anesthesiology, Afliated First Peoples Hospital, Shanghai Jiao Tong University, Shanghai 200080, PR China
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 29 November 2012
Received in revised form 20 May 2013
Accepted 20 May 2013

Background: Intraoperative hypothermia is a common event during laparoscopic


abdominal surgery. On one hand, intraoperative hypothermia can delay the metabolism
and prevent tissue damage. One the other hand, long-term and severe intraoperative
hypothermia may also lead to perioperative complications, such as increasing of
peripheral resistance, coagulation dysfunction, intraoperative hemorrhage and postoperative shivering. Maintenance of normothermia during surgical procedures may
improve the quality of patient care.
Objectives: This study investigated the feasibility and efcacy of intraoperative cutaneous
warming with an underbody warming system during laparoscopic gastrointestinal
surgery.
Methods: 110 patients undergoing laparoscopic surgery for gastrointestinal cancer
between January and December 2011 were randomized into the laparoscopic control
(Control) group and laparoscopic intervention (Intervention) group. Nasopharyngeal
temperature, prothrombin time, activated partial thromboplastin time, and thrombin time
were measured before and during surgery, intraoperative and postoperative complications, as well as shivering after anesthesia and visual analog scale score for pain evaluation
after surgery were also recorded. Clinical risk factors that may cause intraoperative
hypothermia during laparoscopic surgery were also analyzed by correlation analysis.
Results: The two groups were comparable at the baseline. Intraoperative hypothermia was
observed in 29 patients (52.7%) in Control group and 3 (5.5%) in Intervention group.
Nasopharyngeal temperature in Control group was signicantly decreased since 30 min
after the start of operation until the end of surgery comparing to that at the start of
anesthesia, but there was no difference in the Intervention group. In Intervention group,
the nasopharyngeal temperature was remaining at 36.5 8C, indicating the feasibility and
efciency of the underbody warming system in preventing intraoperative hypothermia
during laparoscopic gastrointestinal surgery. Moreover, with anesthesia and operation
time increased, there was no signicant change of coagulation function, hemoglobin level

Keywords:
Hypothermia
Gastrointestinal neoplasm
Laparoscopy
Warming insulation
Blood coagulation disorders
Correlation studies

* Corresponding author. Tel.: +86 21 63240825; fax: +86 21 63240825.


** Co-corresponding author.
E-mail addresses: fang_fang0604@yahoo.com.cn, jeff820722@gmail.com (F. Fang).
1
Contributed equally to this work as co-rst author.
0020-7489/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijnurstu.2013.05.013

182

Y. Pu et al. / International Journal of Nursing Studies 51 (2014) 181189

as well as less intraoperative hemorrhage, less postoperative shivering and lower visual
analog scale score in Intervention group comparing to Control group. Multivariate logistic
regression analysis revealed that anesthesia time and volume of CO2 were independent
risk factors for perioperative hypothermia.
Conclusions: Cutaneous warming with an underbody warming system is a feasible and
effective method to prevent intraoperative hypothermia during laparoscopic gastrointestinal surgery.
2013 Elsevier Ltd. All rights reserved.

What is already known about the topic?


 Intraoperative hypothermia is a common complication
of surgery.
 Intraoperative hypothermia is also observed during
laparoscopic procedures.
What this paper adds
 The underbody warming system is feasible and efcient
in preventing intraoperative hypothermia during laparoscopic gastrointestinal procedure.
 The intraoperative nursing care should focus on intraoperative hypothermia prevention.
1. Introduction
Perioperative hypothermia, dened as a core temperature below 36 8C (Hooper et al., 2009, 2010), is a common
and serious complication of anesthesia and traditional
open surgery (Insler and Sessler, 2006; Knaepel, 2012;
Putzu et al., 2007; Sessler, 2008), occurring in more than
70% of patients (Galvao et al., 2010). The primary
complications of intraoperative hypothermia will increase
mortality rates (Fiedler, 1999; Mahoney and Odom, 1999;
Quiroga et al., 2010; Sessler, 2001), with increasing of
perioperative complications, including susceptible infection at the surgical site (Beilin et al., 1998), cardiac
conduction block and arrhythmia (Fish and Antzelevitch,
2004; Kapetanopoulos et al., 2007), postoperative shivering (Schmied et al., 1996), an increase in blood loss
(Schmied et al., 1996), prolonged as well as altered effects
of anesthetic drugs (Leslie et al., 1995) and impaired
coagulation function (Putzu et al., 2007).
Over the past two decades, the range of laparoscopic
abdominal surgical procedures has grown enormously
(Jakimowicz, 2006), with the vast majority of common
conventional operations on the abdomen now performed
safely, quickly and efciently through laparoscopic techniques (Kuwabara et al., 2011). Hypothermia is an
important complication of open abdominal operations
(Burger and Fitzpatrick, 2009; Pagnocca et al., 2009;
Torossian, 2008), as heat loss occurs from exposure of the
surgical wound and abdominal organs to the ambient
room environment (Diaz and Becker, 2010; Severens et al.,
2010). However, although intraoperative hypothermia was
also observed during laparoscopic procedures (Nguyen
et al., 2001), the mechanism underlying intraoperative
hypothermia during laparoscopic procedures has not been
well elucidated.

In this study, we have testied that intraoperative


hypothermia occurred during laparoscopic gastrointestinal procedure. Moreover, we also investigated the
feasibility and efciency of underbody warming system
in preventing intraoperative hypothermia during laparoscopic gastrointestinal procedure. Furthermore, a quantitative, correlation analysis on the incidence of
intraoperative hypothermia during laparoscopic gastrointestinal was performed. This study elucidated that
anesthesia time and volume of CO2 inated as the possible
risk factors for hypothermia during laparoscopic procedure, which can apply evidence-based guidance for the
intraopertive hypothermia-preventing nursing care. It also
provides a potential feasible and efcient nursing care
protocol on prevention for intraoperative hypothermia
during laparoscopic gastrointestinal surgery, which may
be extended to larger category of minimally invasive
surgeries worldwide.
2. Materials and methods
2.1. Study design and patient selection
The present study is a randomized single-blinded trial
to evaluate the feasibility, efcacy and safety of intraoperative cutaneous warming with an underbody warming
system during laparoscopic gastrointestinal surgery.
Warming intervention can be considered to be promising
as preventing hypothermia (<36 8C) and keeping body
temperature at normal range (37 8C). The hypothetical
noninferiority settings of this study are as follows:
According to our preliminary investigations, 45%
patients were suffered by intraoperative hypothermia if
there was no warming intervention (Suppl Fig. 1);
assuming the number of patients who show intraoperative hypothermia would reduce to 15% after warming
intervention; set the level of a = 0.05 (1-sided) and
b = 0.90. Therefore, the estimated sample size is 94, with
47 cases per arm. In case of irresistible lost of cases, the
study population was set at 110, with 55 cases per arm.
This sample size provides 89% chance of satisfying the
above criteria, under the hypothesis that the expected
complication rate in each arm is less than 10%. This study
was approved by the ethical committee of the Afliated
First Hospital, Shanghai Jiao Tong University, and written
informed consent was obtained from all patients enrolled
in the study.
Supplementary material related to this article found, in
the online version, at http://dx.doi.org/10.1016/j.ijnurstu.
2013.05.013.

Y. Pu et al. / International Journal of Nursing Studies 51 (2014) 181189

183

2.3. Intraoperative data and postoperative evaluations

Fig. 1. Scheme diagram of study design.

Between January 2011 and December 2011, patients


who underwent open and laparoscopic surgery for gastrointestinal tumors in Afliated First Peoples Hospital,
Shanghai Jiao Tong University were consecutively enrolled
in this study (Fig. 1). Exclusion criteria were: body
temperature at arrival in the operating room was
37.5 8C (exclude patients with potential infections) or
<36 8C (exclude patients with preoperative hypothermia),
emergency presentation, morbid obesity (dened as body
mass index > 35 kg/m2), a classication IIIV physical status
according to the American Society of Anesthesiologists.
After conrming the patients met the inclusion/exclusion
criteria, the patients were registered into the trial and then
randomized into the laparoscopic control (Control) group
and laparoscopic intervention (Intervention) group on the
basis of a computer-generated randomization list.
2.2. Surgical intervention and prevention of intraoperative
hypothermia
All laparoscopic procedures were performed by the
same experienced laparoscopic surgery team. The CO2
used for maintaining pneumoperitoneum was not prewarmed (room temperature) and the uids intake during
the operation were room temperature crystalloid solutions. Patients in the Control group were intraoperatively
warmed with a quilt (Fig. 2A and D), while patients in the
Intervention group were intraoperatively warmed with an
disposable underbody warming blanket (Model 545, 585,
3MTM Bair HuggerTM, Saint Paul, MN, USA) with reusable
forced-air warming system (Model 750, 3MTM Bair
HuggerTM) for either horizontal position (Fig. 2B and C)
or lithotomy position (Fig. 2E and F). Prior to use, each
blanket had been sponged and disinfected with a solution
of benzalkonium chloride. Contact skin temperature
greater than 41 8C was not permitted to avoid skin burns.

According to the guidelines to prevent hypothermia of


the American Society of PeriAnesthesia Nurses (Hooper
et al., 2009, 2010), nasopharyngeal temperature of each
patient was measured using an infrared nasopharyngeal
thermometer (Thermor, Newmarket Ontario, Canada),
with a reading accuracy of 0.2 8C. The core body
temperature were measured before anesthesia, right after
anesthesia, right after start of the operation and 10 min
thereafter until the end of anesthesia.
The temperature and humidity of the operating room
were measured using a domestic thermo hygrometer
(Minipa1, Houston, TX, USA) with accuracies of 1 8C and
8% relative humidity, placed approximately 1 m from the
patients head and on the same side of the ear as
nasopharyngeal temperature was measured. Temperature
and humidity were measured when the patient entered the
room, at the beginning of anesthesia induction and every
20 minutes until the end of the anesthetic-surgical procedure. Room temperature was maintained at 2224 8C and
relative humidity at 4060%.
The prothrombin time, activated partial thromboplastin time, and thrombin time were measured at the start of
anesthesia induction, the start of operation, 30 and 60 min
after the start of surgery and at the end of surgery.
Intraoperative blood loss was observed and calculated by
the total volume of uid aspirated out from the abdominal
cavity minus the volume of intra-abdominal lavage.
Intraoperative complications were also recorded. Shivering was assessed at the end of anesthesia, and visual analog
scale were used to assess pain on postoperative day 1, with
0 = none to 10 = worst imaginable. The preoperative and
postoperative (on postoperative day 1), hemoglobin level
were also obtained for further analysis.
2.4. Statistical analysis
All statistical analyses were performed using SPSS for
Windows (Version 13.0; Chicago, IL, USA). Data were
collected prospectively using a computerized data base.
Quantitative data was given as a mean  standard deviation. Data were analyzed using independent Students t-tests,
one-way ANOVA, chi-square tests (1-sided), and Fishers
exact tests (1-sided), where applicable. Factors affecting
intraoperative hypothermia were evaluated by univariate
and multivariate logistic regression analyses. p < 0.05 was
considered statistically signicant.
3. Results
3.1. General clinical features of the two groups
A total of 110 patients were enrolled and analyzed in
this trial: 55 patients in Control and Intervention group,
respectively. There was no statistically signicant difference in type of procedures (Table 1), as well as the majority
of the demographic parameters and intraoperative data
among the two patient populations (Table 1), including
patient gender, age, body mass index, basal body
temperature, arterial pressure, American Society of

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Y. Pu et al. / International Journal of Nursing Studies 51 (2014) 181189

Fig. 2. Disposable underbody warming blanket and reusable forced-air warming system involved in the study. (A) Control group in horizontal position. (B)
Warming blanket for intervention group in horizontal position. (C) Warming blanket for intervention group in horizontal position with patients. (D) Control
group in lithotomy position. (E) Warming blanket for intervention group in lithotomy position. (F) Warming blanket for intervention group in lithotomy
position with patients.

Anesthesiologists score, preoperative comorbid diseases,


anesthesia time, operation time, volumes of CO2 and uids
intake. All patients accepted laparoscopic procedure
successfully and there was no conversion case.
3.2. Intraoperative hypothermia occurred during
laparoscopic gastrointestinal surgery
In order to observe whether hypothermia occurs during
laparoscopic gastrointestinal surgery, we rst investigated
the nasopharyngeal temperature in Control group. Intraoperative hypothermia was observed in 29 of the 55
patients (62.7%) in the Control group. As the operation time

increased, the nasopharyngeal temperature in the Control


group gradually decreased (Fig. 3). There was a signicant
(p < 0.001) temperature drop from 37.03  0.25 8C to
36.56  0.20 8C after the anesthesia induction in Control
group, respectively (Fig. 3). This indicates the effect of
anesthesia on regulating body temperature during laparoscopic surgical procedures (Diaz and Becker, 2010; Lenhardt,
2010; Sessler, 2008). Comparing to the temperature at the
start of anesthesia, there was no signicant alteration in the
temperature at the beginning of surgery until 30 min later
(Fig. 3). The nasopharyngeal temperature was signicantly
(p < 0.0010.05) decreased beginning from 30 min after the
start of surgery until the end of surgery (Fig. 3). Interestingly,

Y. Pu et al. / International Journal of Nursing Studies 51 (2014) 181189

185

Table 1
Demographic and clinical characteristic of the study groups.
Parameters
Gender
Male
Female
Age (years, mean  SD)
Body mass index (kg/m2, mean  SD)
Mean arterial pressure (mmHg, mean  SD)
Surgical procedures
Resection of gastric stromal tumor
Radical resection of gastric cancer
Radical resection of right colon cancer
Radical resection of left colon cancer
Radical resection for sigmoid colon cancer
Radical resection of rectal cancer
Anesthesia time (min, mean  SD)
Operation time (min, mean  SD)
Volume of CO2 (L, mean  SD)
Infused uid (L, mean  SD)

Control group (n = 55)

Intervention group (n = 55)

33
22
67  11 (4383)
22.9  3.6 (1632)
94  12 (69126)

27
28
68  11 (4489)
22.8  3.2 (1533)
95  17 (70134)

3
3
18
6
15
10
166  48 (90360)
146  47 (40300)
199  141 (601000)
1.6  0.4 (0.62.6)

2
2
17
8
18
8
171  48 (90315)
149  46 (60290)
199  118 (23980)
1.5  0.5 (0.62.5)

p
0.569

since 60 min after the surgery begins, the nasopharyngeal


temperature obtained from Control groups was below
36 8C, which represented the intraoperative hypothermia
occurred (Fig. 3). Moreover, since 70 min after the surgery
begins, the nasopharyngeal temperature obtained from
Control group dropped signicantly (p < 0.0010.05) faster
and lower than that obtained from OP group (Suppl Fig. 1).
This indicates that laparoscopic procedure has more
remarkable effect on intraoperative hypothermia than open
procedure. Collectively, these results demonstrated that
intraoperative hypothermia occurs during both long-time
open and laparoscopic gastrointestinal surgery (more than
60 min), while laparoscopic procedure has more conspicuous impact on inducing intraoperative hypothermia than
open procedure.

0.532
0.783
0.645
0.753

0.600
0.552
0.982
0.703

3.3. Preventing intraoperative hypothermia via underbody


warming system in laparoscopic gastrointestinal surgery
Since we have demonstrated that laparoscopic procedure plays crucial role in inducing intraoperative
hypothermia, we then used a well-established underbody
warming system (Egan et al., 2011; Hasegawa et al., 2012;
Sessler, 2008; Trentman et al., 2009) to prevent hypothermia during our laparoscopic gastrointestinal surgery.
Signicantly (p < 0.001) less cases with intraoperative
hypothermia was observed (3 in 55 cases, 5.5%) in the
Intervention group comparing to Control group. Similar to
the Control group, there was a signicant (p < 0.001)
temperature drop from 37.05  0.23 8C to 36.50  0.18 8C
after the anesthesia induction in Intervention group (Fig. 3).
In Intervention group, the nasopharyngeal temperature
obtained was remained at 36.5 8C, which showed a
signicant (p < 0.0010.05) effect on preventing intraoperative hypothermia during our laparoscopic gastrointestinal
surgery comparing to Control group. These results indicate
the feasibility and efciency of the underbody warming
system in preventing intraoperative hypothermia.
3.4. Perioperative evaluation of hypothermia prevention in
laparoscopic gastrointestinal surgery

Fig. 3. Nasopharyngeal temperature in the Control and Intervention


groups at various time points before and during surgery.

Now that the underbody warming system can effectively prevent intraoperative hypothermia during our
laparoscopic gastrointestinal surgery, we further evaluated the inuence of hypothermia prevention toward the
perioperative complications, including intraoperative coagulation dysfunction (Fig. 3), intraoperative hemorrhage,
hemoglobin alteration, shivering, and visual analog scale
score (Table 2).
As we can see in Fig. 4, the intraoperative coagulation
function was investigated in both Control and Intervention
group. The prothrombin time, activated partial thromboplastin time, and thrombin time did not have signicant
alterations from the start of anesthesia to the start of
operation. However, with anesthesia and operation time
extended, there seemed to be a signicant increase of

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186

Table 2
Perioperative evaluation of hypothermia prevention in laparoscopic gastrointestinal surgery.
Parameters
Intraoperative complications
Intraoperative hemorrhage (mL, mean  SD)
150
<150
Organ injury
Equipment disorders
Postoperative complications
Ileus
Anastomotic hemorrhage
Anastomotic leakage
Wound infection
Preoperative hemoglobin (g/L, mean  SD)
Postoperative hemoglobin (g/L, mean  SD)
Postoperative shivering
Yes
No
Visual analog scale score on postoperative day 1
a

Control group (n = 55)

Intervention group (n = 55)

205  209 (10900)


23
32
0
0

146  160 (10600)


15
41
0
0a

0.043

4
1
5
0
121.4  20.1 (91147)
109.5  23.6 (79136)

1
0
2
0
123.2  21.5 (88153)
111.2  20.9 (76140)

0.031

29
26
4.94  2.86

18
37
3.06  1.69

0.778
0.641
0.034

0.041

Including disorders of warming intervention system.

Fig. 4. Detection of coagulation markers at various time points before and


during surgery in the Control and Intervention groups.

prothrombin time (p < 0.0010.05), activated partial


thromboplastin time (p < 0.0010.05) and thrombin time
(p < 0.001) in Control group, which means with time
increases, the coagulation function was suppressed while
intraoperative hypothermia occurred (Fig. 4AC). In
details, the prothrombin time (Fig. 4A) was beyond the
normal range (1214 s) 60 min after start of operation
(14.98  0.66 s, p < 0.001) and by the end of surgery
(16.37  1.45 s, p < 0.001); the activated partial thromboplastin time (Fig. 4B) was beyond the normal range (3243 s)
by the end of surgery (45.35  3.58 s, p < 0.001); the
thrombin time (Fig. 4C) was beyond the normal range (16
18 s) 30 min after start of operation (19.08  0.99 s,
p < 0.001), 60 min after start of operation (21.58  0.92 s,
p < 0.001) and by the end of surgery (23.66  0.77 s,
p < 0.001). Moreover, it was also observed that with
anesthesia and operation time increased, there was no
signicant change of prothrombin time, activated partial
thromboplastin time, and thrombin time comparing to those
at start of anesthesia in Intervention group (Fig. 3AC).
Furthermore, comparing to Control group, there was a
signicant (p < 0.0010.05) benet of preventing abnormalities of prothrombin time, activated partial thromboplastin
time, and thrombin time in Intervention group (Fig. 3AC).
This further supported that hypothermia can affect the
intraoperative coagulation function and preventing intraoperative hypothermia can effectively reverse hypothermiainduced intraoperative coagulation dysfunction.
The hypothermia-induced intraoperative coagulation
dysfunction was ulteriorly supported by the evaluation of
intraoperative hemorrhage between two groups. There
was signicantly (p < 0.01) less intraoperative hemorrhage
after hypothermia prevention in Intervention group
comparing to Control group (Table 2). Other intraoperative
complications such as organ injury and equipment
disorders were not occurred during this study. However,
postoperative complication records indicated that Intervention group had signicant (p = 0.031) less cases of
complications such as ileus, anastomotic hemorrhage and

Y. Pu et al. / International Journal of Nursing Studies 51 (2014) 181189

187

Table 3
Correlation Analysis of Risk Factors Associated with Intraoperative Hypothermia in Control Group.
Parameters

Hypothermia (n = 29)

Normothermia (n = 26)

Univariate analysis
Gender
Male
Female
Age (years)
Body mass index (kg/m2)
Mean arterial pressure (mmHg)
Anesthesia time (min)
Operation time (min)
Volume of CO2 (L)
Intraoperative hemorrhage (mL)
Infused uid (L)

20
9
68  10 (4983)
22.7  2.8 (1830)
97  19 (74126)
212  64 (105360)
186  54 (90300)
284  264 (2001000)
323  244 (20900)
2.0  0.7 (1.02.6)

13
13
65  14 (4380)
23.0  3.0 (1632)
93  10 (69118)
114  41 (90125)
101  69 (40105)
104  82 (60360)
85  31 (10180)
1.2  0.4 (0.62.0)

Parameters

Multivariate analysis
Anesthesia time
Volume of CO2

1.951
1.317

leakage comparing to Control group. Moreover, postoperative shivering was signicantly (p = 0.034) less
common while postoperative visual analog scale score
was signicantly (p = 0.041) lower (3.06  1.69 vs. 4.94  2.
86) in Intervention group comparing to Control group
(Table 2). However, the hemoglobin level did not have
signicant alteration after surgery between two study groups
(Table 2) as there was no transfusion recorded in this series of
cases. Collectively, hypothermia prevention can efciently
work against hypothermia-induced perioperative complications, including intraoperative coagulation dysfunction,
intraoperative hemorrhage, postoperative ileus, anastomotic
hemorrhage, leakage, shivering and pain.
3.5. Correlation analysis for risk factors of intraoperative
hypothermia
The hypothermia is a common complication in laparoscopic surgery. However, there is no systemic investigation
on how laparoscopic procedure affects the body temperature. Therefore, in order to understand the important risk
factors that may cause intraoperative hypothermia during
laparoscopic procedure, correlation analysis was further
performed in Control group (Table 3). Univariate analysis
showed that several risk factors affected perioperative
hypothermia (Table 3), including anesthesia time
(p = 0.003), operation time (p = 0.001), volume of CO2
(p < 0.001), volume of intraoperative hemorrhage
(p = 0.003) and volume of infused uid (p = 0.034).
Moreover, multivariate logistic regression analysis,
including all factors signicantly associated with intraoperative hypothermia in univariate analysis, showed that
anesthesia time (p = 0.016) and volume of CO2 (p = 0.001)
were the independent risk factors for intraoperative
hypothermia (Table 3).
4. Discussion
Intraoperative hypothermia remains one of the most
frequent complications during anesthesia and surgery
(Insler and Sessler, 2006; Knaepel, 2012; Putzu et al., 2007;

0.152
0.907
0.997
0.821
0.003
0.001
<0.001
0.003
0.034

Wald

5.845
11.069

0.016
0.001

Sessler, 2008). Intraoperative mild hypothermia can


reduce the bodys metabolic rate and oxygen consumption
and increase tolerance of tissues and organs to ischemia
and hypoxia (Buggy and Crossley, 2000; Flores-Maldonado
et al., 2001; Putzu et al., 2007; Zhao et al., 2012). However,
long lasting and/or severe hypothermia can lead to
physiological disorders and can increase the perioperative
complication rate (Fiedler, 1999; Mahoney and Odom,
1999; Quiroga et al., 2010; Sessler, 2001). Among the
adverse effects of hypothermia are delayed recovery from
anesthesia (Pagnocca et al., 2009), which can result in
coagulation disorders, increased perioperative blood loss,
and increased rates of wound infection, cardiovascular
morbidity, and shivering behavior (Putzu et al., 2007).
However, whether intraoperative hypothermia occurs and
the mechanism underlying hypothermia during laparoscopic gastrointestinal surgery remains elusive.
To our knowledge, this investigation is the rst to
assess risk factors for intraoperative hypothermia during
laparoscopic gastrointestinal surgery. We found that
intraoperative hypothermia occurred during operations
lasting more than 60 min, with consistent results
showing that laparoscopic surgery lasting more than
60 min required active maintenance of normothermia
(Putzu et al., 2007). Univariate analysis revealed that
anesthesia time, operation time, volume of CO2, volume
of bleeding and volume of uid infusion were correlated
with perioperative hypothermia, whereas multivariate
logistic regression analysis revealed that anesthesia time
and volume of CO2 were the only independent risk
factors for perioperative hypothermia. Anesthetic drugs
inhibit temperature regulation, with volatile anesthetics
causing direct peripheral expansion, increasing the
evaporation of heat. Coupled with anesthetic care itself,
hypothermia can reduce metabolic rate 2030%, leading
to a decline in core temperature (Storey and Storey,
2010). Hypothermia frequently occurs during laparoscopic surgery, due to the exposure of the cavity to great
amounts of insufated CO2 (Birch et al., 2011). Ination
with standard cold-dry CO2 during laparoscopic surgery
has been shown to predispose patients to intraoperative

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Y. Pu et al. / International Journal of Nursing Studies 51 (2014) 181189

hypothermia
(Erikoglu et al., 2005; Hamza et al.,
2005; Neuhaus and Watson, 2004; Ott, 2004). Ination
of heated and humidied CO2 resulted in signicantly
less hypothermia and may be more suitable for CO2
insufations during prolonged laparoscopic surgery
(Birch et al., 2011; Peng et al., 2009; Sajid et al.,
2008). Furthermore, although there seemed not any
inuence of uid infusion on intraoperative hypothermia in our series of cases, we still believe it is important
that applying heating uid in laparoscopic procedure
may prevent intraoperative hypothermia. Nurses play an
important role in the prevention and treatment of
perioperative hypothermia (Hasegawa et al., 2012;
Kuwabara et al., 2011). Thus, perioperative nursing care
is necessary for people at risk for hypothermia. Evaluation of the time of the surgery, monitoring the CO2
ination and uid infusion will be the major intraoperative nursing care indicator for patients who may
have hypothermia during laparoscopic surgery.
Cutaneous warming is the most effective means of
preventing intraoperative hypothermia (Roder et al.,
2011). An underbody warming system can be used for
this purpose (Hooper et al., 2009, 2010). Blankets are now
available that meet international standards of perioperative electrical and thermal safety. We found that,
compared with a quilt, cutaneous warming with a
warming blanket during laparoscopic gastrointestinal
surgery reduced the rate of perioperative hypothermia.
In the Control group, the nasopharyngeal temperature was
signicantly lower since 30 min after the start of operation
and at the end of surgery than at the beginning of the
anesthesia, while in the Intervention group, there were no
signicant differences.
The mechanism by which hypothermia affects blood
coagulation remains unclear (Eddy et al., 2000; Martini,
2009; Thorsen et al., 2011). Low temperature can affect the
function of platelet membrane receptors and platelet
deformation, reducing the number of circulating blood
platelets and the expression of platelet surface membrane
glycoprotein, and inhibiting the release of thromboxane B,
thereby inhibiting platelet adhesion and aggregation
(Harrison, 2005; Rajagopalan et al., 2008; Rumjantseva
and Hoffmeister, 2010). Hypothermia may also decrease
the concentrations of various coagulation factors and
brinogen, inhibiting the coagulation cascade and the
activation of the blood brinolysis system, leading to
reduced coagulation (Marietta et al., 2006). Intraoperative
hypothermia can also result in shivering, increasing
oxygen consumption, carbon dioxide production, myocardial ischemia, cardiac output and intraocular pressure
(Lenhardt, 2010; Neuhaus and Watson, 2004; Ott, 2004). In
evaluating the efcacy of intraoperative cutaneous warming on coagulation index and shivering, we found that the
two groups differed signicantly in coagulation function
30 and 60 min after the start of surgery and at the end of
surgery, and differed signicantly in shivering after
anesthesia. These results conrmed that cutaneous warming with an underbody warming system during laparoscopic gastrointestinal surgery can maintain coagulation
function and prevent shivering, thus improving patient
prognosis.

In summary, this study demonstrates that intraoperative hypothermia occurs during laparoscopic gastrointestinal surgery. Furthermore, This study elucidated the
possible risk factors for hypothermia, which can apply
evidence-based guidance for the intraoperative hypothermia-preventing nursing care. Moreover, cutaneous warming with an underbody warming system is a feasible,
effective and cost efcient method of preventing intraoperative hypothermia during laparoscopic gastrointestinal
surgery. The limitation of this study is that it only focuses
on certain narrow range of patterns of laparoscopic
surgeries. We are looking forward to a large population
of investigation including a wide range of laparoscopic
procedures which may supply stronger evidences for
hypothermia risk predication and prevention in the near
future.
Acknowledgements
We would like to thank all the surgeons, anesthesiologists and nurses that participated in the study and the
consented patients for their contributions to this study.
Conict of interest: The authors declare that there is no
conict of interest.
Funding: This study was supported in part by the
Science and Technology Commission of Shanghai Jiao Tong
University (Project Grant Jyh0913).
Ethical approval: The trial received an approval from
local research ethics committee, and written informed
consent was obtained from all patients before the
investigation.
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