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Vol. 75.
(January 2020)
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Vol. 75.
(January 2020)
ORIGINAL ARTICLE
Open Access
Beneficial effect of fluid warming in elderly patients with bladder cancer undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy
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955
Jianwei LuoI,#, Lin ZhouII,#, Shaoman LinI, Wenchan YanI, Lijuan HuangIII, Sihua LiangIV,
Corresponding author
13642764086@163.com

Corresponding author.
I Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
II Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
III Department of Emergency, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
IV Operating Room, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
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OBJECTIVES:

The enhanced recovery after surgery (ERAS) protocol recommends prevention of intraoperative hypothermia. However, the beneficial effect of maintaining normothermia after radical cystectomy has not been evaluated. This study aimed to investigate the efficacy of fluid warming nursing in elderly patients undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy.

METHODS:

A total of 108 patients with bladder cancer scheduled to undergo DaVinci robotic-assisted laparoscopic radical cystectomy were recruited and randomly divided into the control group (n=55), which received a warming blanket (43°C) during the intraoperative period and the warming group (n=53), in which all intraoperative fluids were administered via a fluid warmer (41°C). The surgical data, body temperature, coagulation function indexes, and postoperative complications were compared between the two groups.

RESULTS:

Compared to the control group, the warming group had significantly less intraoperative transfusion (p=0.028) and shorter hospitalization days (p<0.05). During the entire intraoperative period (from 1 to 6h), body temperature was significantly higher in the warming group than in the control group. There were significant differences in preoperative fibrinogen level, white blood cell count, total bilirubin level, intraoperative lactose level, postoperative thrombin time (TT), and platelet count between the control and warming groups. Multivariate linear regression analysis demonstrated that TT was the only significant factor, suggesting that the warming group had a lower TT than the control group.

CONCLUSION:

Fluid warming nursing can effectively reduce transfusion requirement and hospitalization days, maintain intraoperative normothermia, and promote postoperative coagulation function in elderly patients undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy.

KEYWORDS:
Bladder Cancer
Radical Cystectomy
Hypothermia
Robotic-Assisted Laparoscopic Surgery
Fluid Warming
Full Text
INTRODUCTION

Bladder cancer is the 9th most common malignancy and the 13th leading cause of death worldwide 1. It is primarily a disease of the elderly, with a median age of 72 years at diagnosis 2. Radical cystectomy is the gold standard treatment for muscle-invasive or high-grade non-muscle-invasive bladder cancer 3. With the development of the technique of minimally invasive surgery, Da Vinci robot-assisted radical cystectomy has become the primary and gold standard treatment for bladder cancer as it can better preserve nerve and vessels, which has been shown to reduce blood loss and transfusion, narcotic requirement, time to regular diet, and hospitalization days 35. However, the use of robotic-assisted surgery usually increases the overall operating time and requires prolonged artificial pneumoperitoneum and some special patient positioning, which could affect the patient's pathophysiological conditions and easily induce perioperative hypothermia, especially in the elderly 6. Intraoperative hypothermia can induce a series of perioperative complications, such as postoperative delayed wakefulness, shivering, coagulopathy, agitation, hypoxemia, poor wound healing, and headache 7. It has been shown that intraoperative hypothermia is significantly associated with a higher short-term readmission rate and mortality in elderly patients 8. Despite this, few studies exist on temperature management in Da Vinci robotic-assisted surgery.

Since infusing cold saline or packed red blood cells causes a marked decrease in patient's body temperature 9, pre-warmed infusions (to 38–42°C) is an important strategy to maintain intraoperative normothermia 10,11. The common methods of pre-warmed infusions include a double-wall infusion line and a fluid warming device 12,13. Intravenous fluids warming is one of the most effective strategies for intraoperatively maintaining normothermia 14,15. Intravenous fluid warming has been shown to effectively maintain the core temperature in laparoscopic colorectal surgery 16. The Enhanced Recovery After Surgery (ERAS) Society guidelines for perioperative care after radical cystectomy for bladder cancer strongly recommend prevention of intraoperative hypothermia 17. However, the beneficial effect of maintaining normothermia during radical cystectomy has not been evaluated18. Therefore, this study aimed to investigate the efficacy of fluid warming in elderly patients with bladder cancer undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy.

METHODSParticipants and study design

A total of 108 patients with bladder cancer scheduled to undergo DaVinci robotic-assisted laparoscopic radical cystectomy were recruited into this trial. Other inclusion criteria were American Society of Anesthesiologists (ASA) Score I-III and age 50-79 years. Patients with a history of cerebral infarction, mental abnormalities, preoperative urinary tract infection, or severe lung infection or disease were excluded. This study was approved by the institutional review board of our hospital and written informed consent was waived by the Institutional Review Board due to the retrospective nature of this study.

Fluid warming protocol

Prior to the study, all nursing staff received training for the procedure of fluid warming and the data collection. The 108 enrolled patients were randomly divided into the control group (n=55) and the warming group (n=53). All patients underwent Da Vinci robot-assisted laparoscopic radical cystectomy at room temperature under the same anesthesia treatment.

In the warmed fluid group, all intraoperative fluids were administered via the Ranger™ Blood/Fluid Warming Unit (3M, St. Paul, MN, USA) using a setpoint of 41°C. The patients in the control group used a warming blanket (setpoint=43°C) during the intraoperative period.

Data collection

Demographic (sex, age) and baseline clinical characteristics (ASA score, Cardiac function (assessed by determining the ejection fraction), and body mass index [BMI]) were collected. Surgical information included intraoperative transfusion, intraoperative blood loss, intraoperative warming time of transfusion, operative time, anesthesia time, recovery room to extubation time, post-anesthesia care unit (PACU) stay time, postoperative flatulence, loss of blood, reoperation due to bleeding, hospitalization days, and medical expenses.

Patient's nasopharyngeal temperature was measured using the Carefusion Temperature Probe (400 Series, GE Healthcare, USA) with the Carescape Monitor B650, GE Healthcare) during the whole perioperative period. Biochemical examination results including coagulation function indexes (prothrombin time activated partial thromboplastin time, thrombin time), fibrinogen; white blood cell, platelet, total bilirubin, pH, glucose, lactose were collected during the perioperative period.

Postoperative complications including cold shivering, pneumonia, pulmonary embolism, urinary fistula, and intestinal obstruction were recorded. All data was compared between the two groups.

Statistical analysis

Continuous variables were presented as mean±SD (standard deviation) while categorical data were indicated by number and percentage (%). Student's independent t-test was used to compare the differences between groups. If normality of continuous variables was not assumed, median (range) and non-parametric analysis Mann-Whitney U test would be used instead. Chi-square test and Fisher's exact test (if any expected value lower than 5 was observed) were used for categorical data. Two-way mixed design ANOVA was used to test the significance of main effect (time, group) and interaction effect (time*group). Univariate and multivariate linear regression models were used to investigate the significance of group factor to the differences between pre/peri-operative and postoperative index. A p-value lower than 0.05 would be recognized as reaching significance of each test. All analyses were performed using IBM SPSS Version 20 (SPSS Statistics V20, IBM Corporation, Somers, New York).

RESULTSDemographic and clinical characteristics

A total of 108 patients (mean age= 62.20±11.05 years, range: 26-87, 82.41% male) undergoing DaVinci assisted laparoscopic radical cystectomy were enrolled, and randomly divided into the warming group (n=53) and control group (n=55). There was no significant difference in demographic and clinical characteristics between the warming and control groups (all p>0.05, Table 1).

Table 1.

Demographic and clinical characteristics.

Parameters  Control (n=55)  Warming (n=53)  Total (n=108)  p 
Sex        0.240 
Male  43 (78.18)  46 (86.79)  89 (82.41)   
Female  12 (21.82)  7 (13.21)  19 (17.59)   
Age, years  63.55±10.38  60.81±11.65  62.20±11.05  0.155 
ASA classification        0.124 
II  23 (41.82)  30 (56.60)  53 (49.07)   
III  32 (58.18)  23 (43.40)  55 (50.93)   
Cardiac functiona  0.66±0.06  0.66±0.05  0.66±0.06  0.850 
BMI  23.04±3.20  23.44±2.83  23.24±3.02  0.545 

ASA, American Society of Anesthesiologists; BMI, Body Mass Index.

a

Cardiac function was assessed by determining the ejection fraction (EF).

Perioperative information

The perioperative information was compared between the two groups. As shown in Table 2, the warming group had significantly less intraoperative transfusion (p=0.028) and shorter hospitalization days (both postoperative and total hospitalization, p<0.05) than the control group. However, there was no significant difference in perioperative blood loss, operative time, anesthesia time, time from entering recovery room to extubation, PACU stay time, time to postoperative flatulence, blood loss, reoperation due to bleeding, and medical expenses (all p>0.05).

Table 2.

Patient's operative information.

Parameters  Control (n=55)  Warming (n=53)  Total (n=108)  p 
Intraoperative transfusion, ml  2153.64±671.91  1903.30±491.32  2030.79±600.80  0.028 
Intraoperative blood loss, ml  212.73±525.31  141.13±108.82  177.59±382.50  0.193 
Intraoperative warming time of transfusion, min  336.43±88.91  336.43±88.91 
Operative time, min  346.51±94.85  322.57±81.29  334.76±88.86  0.190 
Anesthesia time, min  507.38±104.83  476.68±93.28  492.31±100.06  0.132 
Recovery room to extubation time, min  26.39±12.70  26.62±14.31  26.50±13.44  0.909 
PACU stay time, min  70.17±19.55  75.91±27.84  72.90±23.90  0.410 
Postoperative flatulence, day  3.71±1.71  3.70±1.39  3.70±1.55  0.768 
Loss of blood, ml         
Operative day  429.42±214.71  431.32±164.92  430.35±191.01  0.268 
Day 1 after surgery  434.04±274.84  421.36±181.62  427.81±232.79  0.683 
Day 2 after surgery  326.73±203.61  313.72±180.74  320.34±191.94  0.822 
Day 3 after surgery  300.27±269.22  312.06±271.74  305.83±269.16  0.718 
Reoperation due to bleeding        0.580 
No  53 (96.36)  52 (98.11)  105 (97.22)   
Yes  2 (3.64)  1 (1.89)  3 (2.78)   
Hospitalization, days         
Postoperative  20 (5-75)  16 (5-48)  18 (5-75)  <0.001 
Total  34.07±10.87  23.62±6.82  28.94±10.48  <0.001 
Medical expenses         
Anesthesia  12056.21 (9285.64-23325.39)  12861.46 (7923.50-19068.38)  12478.44 (7923.50-23325.39)  0.557 
Total  107026.61 (79421.88-359872.75)  103629.18 (82531.73-183466.73)  105198.58 (79421.88-359872.75)  0.823 

PACU; post-anesthesia care unit.

Change of body temperature during the perioperative period

Patient's body temperature was recorded at preoperative, intraoperative and postoperative periods. As shown in Table 3, during the entire intraoperative period (from 1 to 6h), the warming group had significantly higher body temperature than the control group (all p<0.05). No significance was found in preoperative and recovery room periods (p>0.05). At day 3 after the operation, the body temperature was slightly but significantly higher in control group than in the warming group (p<0.05).

Table 3.

Change in the patient's body temperature during the perioperative period.

Parameters  Control (n=55)  Warming (n=53)  Total (n=108)  p 
Preoperative  36.45±0.36  36.48±0.35  36.47±0.35  0.641 
Intraoperative         
1 hour  36.05±0.42  36.22±0.47  36.13±0.45  0.036 
2 hours  35.80±0.39  36.14±0.45  35.97±0.45  <0.001 
3 hours  35.54±0.44  36.10±0.40  35.81±0.50  <0.001 
4 hours  35.27±0.39  36.09±0.39  35.67±0.56  <0.001 
5 hours  35.06±0.34  36.12±0.30  35.55±0.62  <0.001 
6 hours  34.90±0.30  36.01±0.33  35.29±0.62  <0.001 
Postoperative         
In recovery room  36.25±0.38  36.12±0.38  36.19±0.38  0.103 
Back to the ward  36.42±0.37  36.47±0.39  36.44±0.38  0.564 
Day 1  37.07±0.44  36.95±0.43  37.01±0.44  0.160 
Day 2  36.92±0.42  36.87±0.32  36.89±0.37  0.310 
Day 3  36.93±0.54  36.74±0.30  36.84±0.45  0.024 
Perioperative laboratory results

Laboratory results were compared between groups. There were significant differences in preoperative FIB, white blood cell, total bilirubin; intraoperative lactose; and postoperative thrombin time (TT) between the control and warming groups (all p<0.05, Table 4). The difference between pre- and postoperative TT was also different between groups (p=0.004, Table 4).

Table 4.

Laboratory results during perioperative period.

Parameters  Control (n=55)  Warming (n=53)  Total (n=108)  p 
Preoperative         
PT  11.83±0.82  11.61±0.92  11.72±0.87  0.121 
APTT  25.59±4.33  25.34±4.00  25.46±4.15  0.907 
TT  18.23±2.82  17.32±1.86  17.78±2.43  0.080 
FIB  3.78±2.92  3.07±1.17  3.43±2.25  0.034 
WBC  6.51±2.06  7.78±2.90  7.14±2.58  0.023 
Platelet  229.96±59.78  259.09±71.17  244.26±66.92  0.056 
Total bilirubin  13.36±4.91  11.13±3.93  12.27±4.58  0.012 
Intraoperative (average)         
PH  7.31±0.06  7.33±0.05  7.32±0.06  0.210 
GUL  6.27±1.12  6.26±1.13  6.27±1.12  0.875 
LAC  0.69±0.20  0.85±0.39  0.77±0.31  0.016 
Postoperative         
PT  15.44±13.46  12.33±0.89  13.99±9.91  0.069 
APTT  30.41±9.21  27.14±4.84  28.89±7.62  0.245 
TT  17.84±5.19  15.72±1.48  16.85±4.04  0.010 
FIB  3.67±1.40  3.32±0.99  3.50±1.23  0.450 
WBC  11.05±4.30  12.22±4.12  11.62±4.24  0.219 
Platelet  187.91±53.33  229.83±67.46  208.48±63.95  0.002 
Total bilirubin  14.26±5.90  13.59±6.81  13.93±6.34  0.378 
pH  7.34±0.04  7.35±0.04  7.35±0.04  0.084 
GUL  7.18±1.75  7.10±1.98  7.14±1.85  0.453 
LAC  1.18±0.68  1.25±0.69  1.21±0.68  0.414 
Difference between preoperative and postoperative period         
PT  3.50±13.40  0.66±1.13  2.18±9.86  0.156 
APTT  4.14±6.30  1.53±3.89  2.93±5.43  0.127 
TT  0.26±4.44  -2.14±2.42  -0.86±3.81  0.004 
Fibrinogen  0.24±1.23  0.46±1.39  0.35±1.30  0.457 
WBC  4.53±4.33  4.43±3.67  4.48±4.01  0.939 
Platelet  ++  -29.26±36.51  -35.78±36.56  0.161 
Total bilirubin  0.89±5.58  2.46±5.83  1.66±5.73  0.265 
pH  0.03±0.06  0.02±0.05  0.03±0.05  0.887 
Glucose  0.87±1.48  0.85±1.54  0.86±1.50  0.430 
Lactose  0.48±0.69  0.42±0.65  0.46±0.67  0.958 

PT, prothrombin time; APTT, activated partial thromboplastin time; TT, thrombin time; WBC, white blood cell; Platelet; pH.

Linear regression was used to investigate the effect of group factor on the differences between preoperative/intraoperative and postoperative results. The multivariate model was controlled with patient's age, gender, and ASA classification. The result showed that TT was the only significant factor (Table 5), suggesting that the warming group had lower TT level than the control group.

Table 5.

Univariate and multivariate linear regression results.

  Linear regression
  UnivariateMultivariate
  B (95% CI)  p  B (95% CI)  p 
PT  -2.84 (-8.03-2.34)  0.277  -3.11 (-8.72-2.51)  0.272 
APTT  -2.61 (-5.42-0.19)  0.067  -1.59 (-4.37-1.20)  0.259 
TT  -2.40 (-4.32–0.48)  0.015  -2.46 (-4.47–0.44)  0.018 
Fibrinogen  0.22 (-0.47-0.92)  0.522  0.30 (-0.45-1.05)  0.426 
WBC  -0.10 (-1.63-1.44)  0.900  -0.08 (-1.64-1.48)  0.920 
Platelet  12.79 (-1.01-26.59)  0.069  11.17 (-2.83-25.17)  0.117 
Total bilirubin  1.57 (-0.61-3.74)  0.156  1.53 (-0.71-3.77)  0.178 
pH  0.00 (-0.03-0.02)  0.743  0.00 (-0.03-0.02)  0.871 
Glucose  -0.02 (-0.65-0.61)  0.952  0.03 (-0.63-0.68)  0.935 
Lactose  -0.06 (-0.34-0.22)  0.677  0.00 (-0.29-0.28)  0.975 

PT, prothrombin time; APTT, activated partial thromboplastin time; TT, thrombin time; WBC, white blood cell; Platelet; pH.

Postoperative complications

There was no significant difference in postoperative complications between the two groups, including cold shivering in the recovery room, pneumonia, pulmonary embolism, urinary fistula, and intestinal obstruction (Table 6, all p>0.05).

Table 6.

Postoperative complications.

Parameters  Control (n=55)  Warming (n=53)  Total (n=108)  p 
Cold shiver in recovery room        0.282 
No  38 (70.37)  39 (79.59)  77 (74.76)   
Yes  16 (29.63)  10 (20.41)  26 (25.24)   
Pneumonia        0.963 
No  52 (94.55)  50 (94.34)  102 (94.44)   
Yes  3 (5.45)  3 (5.66)  6 (5.56)   
Pulmonary embolism       
No  55 (100.00)  53 (100.00)  108 (100.00)   
Yes   
Urinary fistula        0.687 
No  39 (70.91)  35 (67.31)  74 (69.16)   
Yes  16 (29.09)  17 (32.69)  33 (30.84)   
Intestinal obstruction        0.378 
No  37 (67.27)  39 (75.00)  76 (71.03)   
Yes  18 (32.73)  13 (25.00)  31 (28.97)   
DISCUSSION

Under normal physiological conditions, the body core temperature fluctuates only within a narrow range (about ±0.2°C), while under anesthesia, the range is significantly increased to ±4°C 19. In addition, body temperature under anesthesia is more easily affected by external factors. Robot-assisted laparoscopic radical cystectomy increases the overall operating time and requires prolonged anesthesia 6. Most of the patients receiving radical cystectomy are elderly and are therefore more likely to develop perioperative hypothermia than young patients due to the degeneration of their body homeostasis ability. Therefore, maintaining normothermia is an important measure to reduce perioperative complications.

At present, intraoperative temperature maintaining devices include forced-air warming blankets, heating mattresses, circulating-water garment systems 20, and fluid warming system 16. The disadvantage of warming blankets and heating mattresses is that the temperature sensor of elderly patients may degenerate, which may cause burns or thermal hypersensitivity. Water in circulating-water garment systems is considered as a potential source of pathogen contamination in hospitals and can be a source of infection if not properly maintained. The fluid warming system supplies heat by inserting the infusion catheter into the metal heating plate without circulating water. Constant-temperature fluids or blood can be delivered into every part of the body. Choi et al. have demonstrated that intravenous fluid warming can effectively maintain intraoperative normothermia in patients undergoing laparoscopic colorectal surgery 16. However, the effectiveness of warming intravenous fluid has not been evaluated in robotic-assisted laparoscopic surgery.

In this study, we investigated the efficacy of fluid warming in elderly patients undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy. The results showed that during the entire intraoperative period, body temperature was significantly higher in the warming group than in the control group. Especially at 6h after surgery start, the core temperature dropped to 34.9°C in the control group but still maintained at 36.01°C in the warming group. This data suggested that our fluid warming protocol can effectively maintain normothermia during operation, which is consistent with the results of the studies conducted in laparoscopic colorectal surgery 16.

In the current study, the warming group had significantly less intraoperative transfusion than the control group, suggesting that fluid warming can significantly reduce intraoperative transfusion requirement. This finding is in line with the results of a meta-analysis, including 10 studies by Rajagopalan et al., which shows that mild hypothermia (decrease by <1°C) significantly increases blood loss by approximately 16% and increases transfusion risk by 22% 21. By contrast, maintaining intraoperative normothermia can effectively reduce blood loss and transfusion requirement 21. However, although the intraoperative blood loss was less in the warming group than in the control group (141.13±108.82 vs. 212.73±525.31 mL) in our study, the difference did not reach statistical significance. One possible explanation might be that the advantages of reducing blood loss by fluid warming may be reduced in robotic-assisted laparoscopic surgery.

Intraoperative hypothermia has been shown to reduce the level of circulating platelets and platelets function 21,22. Supporting this notion, our study showed that the warming group had a higher postoperative platelet count compared with the control group. On the other hand, we observed that the warming group had significantly shorter postoperative TT than the control group. Multivariate linear regression analysis confirmed that the warming group had shorter TT than the control group, suggesting that fluid warming can improve the postoperative coagulation function. Intraoperative hypothermia is known to induce coagulopathy by impairing several enzymes of the coagulation cascade, eventually reducing clot formation 7. Both impaired function of platelets and coagulation can lead to increase bleeding time and intraoperative blood loss.

Yi et al. conducted a national cross-sectional study in China on 3,132 patients under general anesthesia, and the results demonstrate that intraoperative hypothermia would increase intensive care unit (ICU) admissions and prolonged hospitalization days 23. Kurz et al. have demonstrated that maintaining normothermia intraoperatively by combining intravenous fluids warming and forced-air cover can effectively decrease the incidence of infectious complications and hospitalization days 15. In agreement with these observations, our study also found that compared to the control group, the warming group had shorter hospitalization days. This observation indicated that fluid warming can promote postoperative recovery.

CONCLUSIONS

In summary, this study demonstrated that fluid warming can effectively reduce transfusion requirement and hospitalization days, maintain intraoperative normothermia and promote postoperative coagulation function in elderly patients undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy, which is worth further clinical application.

AUTHOR CONTRIBUTIONS

The authors declare that all of them have participated actively in the study and all meet the requirements for the authorship. Liang S designed the study and wrote the protocol. Luo J, Zhou L and Lin S corrected the data. Yan W and Huang L interpreted the data. Luo J and Zhou L performed the statistical analysis. Luo J wrote the first draft of the manuscript and mainly revised the manuscript. All authors approved the final version of the manuscript.

ACKNOWLEDGMENTS

This study was supported by the Nursing Research Fund of Sun Yat-sen Memorial Hospital (2017).

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No potential conflict of interest was reported.

These authors contributed equally to this work.

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