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Chicote Álvarez, A. González Castro, M. Ortiz Lasa, A. Jiménez Alfonso, P. Escudero Acha, J.C. Rodríguez Borregán, Y. Peñasco Martín, T. Dierssen Sotos" "autores" => array:8 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Chicote Álvarez" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "González Castro" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Ortiz Lasa" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Jiménez Alfonso" ] 4 => array:2 [ "nombre" => "P." "apellidos" => "Escudero Acha" ] 5 => array:2 [ "nombre" => "J.C." "apellidos" => "Rodríguez Borregán" ] 6 => array:2 [ "nombre" => "Y." "apellidos" => "Peñasco Martín" ] 7 => array:2 [ "nombre" => "T." 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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "543" "paginaFinal" => "545" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Álvarez, P. Argente" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Álvarez" "email" => array:1 [ 0 => "julian.alvarez@usc.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Argente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Catedrático y Jefe del Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario, Decano, Facultad de Medicina y Odontología, Universidad de Santiago de Compostela, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Jefa del Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Directora del Área Quirúrgica. Hospital Universitari i y Politécnic de La Fe, Profesora Asociada de Anestesiología, Reanimación, Facultad de Medicina y Odontología, Universidad de Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hipotermia no intencional en el paciente quirúrgico. ¿Viejos problemas y viejas soluciones o viejos problemas y nuevas soluciones?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">On November 16, 1846, William Thomas Green Morton administered ether to a patient, thus achieving what is considered the first scientific anaesthesia in history.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">1</span></a> The complications of this novel technique soon became obvious. Since then, clinicians have been aware of the role of anaesthesia in perioperative morbidity and mortality, a topic that has been explored extensively in the literature.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Morton, however, was no doubt ignorant of the effect that anaesthesia, together with increasingly complex surgical interventions, would have on the homeostasis of all organs and systems, and also the regulation of body temperature.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Scientists first started to take an interest in temperature in the surgical patient at the end of the 19th century, when Harvey Cushing, a medical student, together with his classmate, Ernest Amory Codman, proposed monitoring several physiological parameters during surgery, among them temperature,<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">4,5</span></a> and laid the foundations of the modern practice of anaesthesia monitoring.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In 1986, Eichhorn<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a> published his monitoring standards, which would later be called “minimum monitoring”. These standards radically and definitively changed the safety of the anaesthetised patient, and were adopted almost immediately by anaesthesia associations worldwide, the SEDAR among them.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">7,8</span></a> Eichhorn's standards are contained in his “White Book”, which we hope to publish in the near future.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Temperature is one of the parameters included in these monitoring standards, and as such appears in all documents related to patient safety.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Although the literature abounds with reports on intraoperative temperature increase, particularly due to drugs, malignant hyperthermia, hyperthermia or neuroleptic-induced hyperpyrexia,<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">11,12</span></a> the most pressing topic today is unintentional hypothermia in the surgical patient. This frequently overlooked complication can have serious consequences for the patient. These can be summarised as: coagulation changes, delayed healing, increased risk of wound infection, pharmacological alterations, haemodynamic changes, and increased need for oxygen, among others.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">13–16</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Both anaesthetic and surgical techniques are known to promote heat loss, thus creating a double risk. In this editorial we will not go into details, but we are convinced that the responsibility of monitoring, preventing and treating unintentional hypothermia must lie with the anaesthesiologist.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">17</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The aetiology and pathogenesis of this complication is well known,<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">18–24</span></a> and has been extensively reported in the literature. It is beyond the scope of this editorial to analyse unintentional hypothermia, mainly because the subject has been explored in depth in the guidelines published in this edition of our journal.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Suffice to say that, despite overwhelming evidence, temperature monitoring is not even as remotely widespread that of other parameters, such as pulse oximetry or capnography.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">26</span></a> Because of this, unintentional hypothermia is a common occurrence in our hospitals, and has a direct effect on the perioperative outcomes of major surgery in particular,<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a> but also of more minor procedures, including outpatient surgery.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">29</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The question we ask in this editorial is very simple: Why is temperature monitoring not more widespread? Or at least, why is monitoring not used would it be of benefit for both the patient and the perioperative outcomes?</p><p id="par0055" class="elsevierStylePara elsevierViewall">All opinions on this subject are reasonable, but they cannot and should not be simple. To simplify would be to underestimate the problem; and the reality, far from being simple, is multifaceted. Temperature monitoring is side-lined for several reasons that, in our opinion, merit analysis. These are:</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Current guidelines state that temperature does not need to be monitored in all situations</span><p id="par0060" class="elsevierStylePara elsevierViewall">Guidelines advise against monitoring temperature in short, minimally invasive surgical procedures. As a result, such monitoring is not routine, and is omitted in many situation where it could be of benefit. This could prompt the following reflection: <span class="elsevierStyleItalic">“We would never dream of performing a procedure without pulse oximetry, but we have no problem performing numerous procedures without temperature monitoring</span>.<span class="elsevierStyleItalic">”</span></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">The biological deterioration caused by moderate hypothermia is not immediately apparent</span><p id="par0065" class="elsevierStylePara elsevierViewall">As we have seen, hypothermia is a potentially serious complication, but its most important effects do not usually appear either during surgery or in the immediate postoperative period. It lacks the immediacy of hypoxia or hypotension.</p><p id="par0070" class="elsevierStylePara elsevierViewall">We know that hypothermia causes chills, increases oxygen demand and consumption, alters the immune response, delays scarring, produces metabolic acidosis, alters awakening after general anaesthesia, alters the average life of anaesthetic drugs, and triples the incidence of coagulation disorders and postoperative infections, among many other effects.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">18–21</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">However, the delayed effects of intraoperative hypothermia prompt many clinicians to defer their responsibility, and they neither monitor temperature nor adopt effective systematic measures to prevent this condition.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">The considerable variability between systems and methods of preventing and treating intraoperative hypothermia</span><p id="par0080" class="elsevierStylePara elsevierViewall">There are many ways of preventing and treating intraoperative hypothermia, and because of this these systems are seldom protocolised in anaesthesiology services. The sheer abundance of options makes it difficult to use the simplest and frequently most effective systems.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">22–29</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Poor resource management</span><p id="par0085" class="elsevierStylePara elsevierViewall">Hypothermia is a complication, which, like all complications significantly increases health care costs. Prevention of hypothermia is undoubtedly cost-effective.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Some authors argue that maintaining normothermia is generally difficult and expensive,<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">30,31</span></a> but numerous simple, inexpensive devices have proven their effectiveness and require minimum training.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Training and research into intraoperative hypothermia depends to a large extent on third-party funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">We are all aware of the important role of industry in research and health care training. Industry-funded research and training is perfectly ethical, provided authors declare their conflict of interest, and is essential to guarantee the quality of the system. However, these actions must be endorsed by scientific societies, and complemented by the professionals most closely involved with quality and patient safety. This has not always been the case, and unfortunately temperature remains the “Cinderella” of monitoring in our hospitals.</p><p id="par0100" class="elsevierStylePara elsevierViewall">This <span class="elsevierStyleItalic">clinical practice guideline for unintentional perioperative hypothermia</span> helps to clarify the problem by analysing and proposing solutions to a very real and pressing problem.</p></span><span id="sec1025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1085">Conflict of interests</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Current guidelines state that temperature does not need to be monitored in all situations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "The biological deterioration caused by moderate hypothermia is not immediately apparent" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "The considerable variability between systems and methods of preventing and treating intraoperative hypothermia" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Poor resource management" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Training and research into intraoperative hypothermia depends to a large extent on third-party funding" ] 5 => array:2 [ "identificador" => "sec1025" "titulo" => "Conflict of interests" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-29" "fechaAceptado" => "2018-10-29" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Álvarez J, Argente P. Hipotermia no intencional en el paciente quirúrgico. ¿Viejos problemas y viejas soluciones o viejos problemas y nuevas soluciones? Rev Esp Anestesiol Reanim. 2018;65:543–545.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:31 [ 0 => array:3 [ "identificador" => "bib0160" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Historical development of modern anesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.H. Robinson" 1 => "A.H. 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Unintentional hypothermia in the surgical patient. Old solutions to an old problem, or new solutions to an old problem?
Hipotermia no intencional en el paciente quirúrgico. ¿Viejos problemas y viejas soluciones o viejos problemas y nuevas soluciones?
a Catedrático y Jefe del Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario, Decano, Facultad de Medicina y Odontología, Universidad de Santiago de Compostela, Spain
b Jefa del Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Directora del Área Quirúrgica. Hospital Universitari i y Politécnic de La Fe, Profesora Asociada de Anestesiología, Reanimación, Facultad de Medicina y Odontología, Universidad de Valencia, Spain