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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
Keywords:
Hypothermia
Gastrointestinal neoplasm
Laparoscopy
Warming insulation
Blood coagulation disorders
Correlation studies
182
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.
183
184
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.
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)
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
0.532
0.783
0.645
0.753
0.600
0.552
0.982
0.703
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
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
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
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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
188
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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