Unintentional hypothermia in the surgical patient. Old solutions to an old problem, or new solutions to an old problem?

Álvarez, J.; Argente, P.
doi:10.1016/j.redare.2018.11.006
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">On November 16&#44; 1846&#44; William Thomas Green Morton administered ether to a patient&#44; thus achieving what is considered the first scientific anaesthesia in history&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">1</span></a> The complications of this novel technique soon became obvious&#46; Since then&#44; clinicians have been aware of the role of anaesthesia in perioperative morbidity and mortality&#44; a topic that has been explored extensively in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Morton&#44; however&#44; was no doubt ignorant of the effect that anaesthesia&#44; together with increasingly complex surgical interventions&#44; would have on the homeostasis of all organs and systems&#44; and also the regulation of body temperature&#46;</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&#44; when Harvey Cushing&#44; a medical student&#44; together with his classmate&#44; Ernest Amory Codman&#44; proposed monitoring several physiological parameters during surgery&#44; among them temperature&#44;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">4&#44;5</span></a> and laid the foundations of the modern practice of anaesthesia monitoring&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In 1986&#44; Eichhorn<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a> published his monitoring standards&#44; which would later be called &#8220;minimum monitoring&#8221;&#46; These standards radically and definitively changed the safety of the anaesthetised patient&#44; and were adopted almost immediately by anaesthesia associations worldwide&#44; the SEDAR among them&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">7&#44;8</span></a> Eichhorn&#39;s standards are contained in his &#8220;White Book&#8221;&#44; which we hope to publish in the near future&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Temperature is one of the parameters included in these monitoring standards&#44; and as such appears in all documents related to patient safety&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Although the literature abounds with reports on intraoperative temperature increase&#44; particularly due to drugs&#44; malignant hyperthermia&#44; hyperthermia or neuroleptic-induced hyperpyrexia&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">11&#44;12</span></a> the most pressing topic today is unintentional hypothermia in the surgical patient&#46; This frequently overlooked complication can have serious consequences for the patient&#46; These can be summarised as&#58; coagulation changes&#44; delayed healing&#44; increased risk of wound infection&#44; pharmacological alterations&#44; haemodynamic changes&#44; and increased need for oxygen&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">13&#8211;16</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Both anaesthetic and surgical techniques are known to promote heat loss&#44; thus creating a double risk&#46; In this editorial we will not go into details&#44; but we are convinced that the responsibility of monitoring&#44; preventing and treating unintentional hypothermia must lie with the anaesthesiologist&#46;<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&#44;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">18&#8211;24</span></a> and has been extensively reported in the literature&#46; It is beyond the scope of this editorial to analyse unintentional hypothermia&#44; mainly because the subject has been explored in depth in the guidelines published in this edition of our journal&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Suffice to say that&#44; despite overwhelming evidence&#44; temperature monitoring is not even as remotely widespread that of other parameters&#44; such as pulse oximetry or capnography&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">26</span></a> Because of this&#44; unintentional hypothermia is a common occurrence in our hospitals&#44; and has a direct effect on the perioperative outcomes of major surgery in particular&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a> but also of more minor procedures&#44; including outpatient surgery&#46;<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&#58; Why is temperature monitoring not more widespread&#63; Or at least&#44; why is monitoring not used would it be of benefit for both the patient and the perioperative outcomes&#63;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All opinions on this subject are reasonable&#44; but they cannot and should not be simple&#46; To simplify would be to underestimate the problem&#59; and the reality&#44; far from being simple&#44; is multifaceted&#46; Temperature monitoring is side-lined for several reasons that&#44; in our opinion&#44; merit analysis&#46; These are&#58;</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&#44; minimally invasive surgical procedures&#46; As a result&#44; such monitoring is not routine&#44; and is omitted in many situation where it could be of benefit&#46; This could prompt the following reflection&#58; <span class="elsevierStyleItalic">&#8220;We would never dream of performing a procedure without pulse oximetry&#44; but we have no problem performing numerous procedures without temperature monitoring</span>&#46;<span class="elsevierStyleItalic">&#8221;</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&#44; hypothermia is a potentially serious complication&#44; but its most important effects do not usually appear either during surgery or in the immediate postoperative period&#46; It lacks the immediacy of hypoxia or hypotension&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">We know that hypothermia causes chills&#44; increases oxygen demand and consumption&#44; alters the immune response&#44; delays scarring&#44; produces metabolic acidosis&#44; alters awakening after general anaesthesia&#44; alters the average life of anaesthetic drugs&#44; and triples the incidence of coagulation disorders and postoperative infections&#44; among many other effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">18&#8211;21</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">However&#44; the delayed effects of intraoperative hypothermia prompt many clinicians to defer their responsibility&#44; and they neither monitor temperature nor adopt effective systematic measures to prevent this condition&#46;</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&#44; and because of this these systems are seldom protocolised in anaesthesiology services&#46; The sheer abundance of options makes it difficult to use the simplest and frequently most effective systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">22&#8211;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&#44; which&#44; like all complications significantly increases health care costs&#46; Prevention of hypothermia is undoubtedly cost-effective&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Some authors argue that maintaining normothermia is generally difficult and expensive&#44;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">30&#44;31</span></a> but numerous simple&#44; inexpensive devices have proven their effectiveness and require minimum training&#46;</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&#46; Industry-funded research and training is perfectly ethical&#44; provided authors declare their conflict of interest&#44; and is essential to guarantee the quality of the system&#46; However&#44; these actions must be endorsed by scientific societies&#44; and complemented by the professionals most closely involved with quality and patient safety&#46; This has not always been the case&#44; and unfortunately temperature remains the &#8220;Cinderella&#8221; of monitoring in our hospitals&#46;</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&#46;</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&#46;</p></span></span>"
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