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Unintentional perioperative hypothermia is associated with severe complications and high mortality in elective operations

      Introduction

      Hypothermia occurs in as many as 7% of elective colorectal operations and is an underestimated risk factor for complications and death. Rewarming of hypothermic patients alone is not sufficient to prevent such adverse events. We investigated the outcomes of patients who became hypothermic (<35°C) after elective operations and compared them with closely matched, nonhypothermic operative patients to better define the impact of hypothermia on surgical outcomes, as well as to identify independent risk factors for hypothermia.

      Methods

      We queried the University HealthSystem Consortium (UHC) database for elective operative patients who became unintentionally hypothermic from October 2008 to March 2012, and identified 707 patients. Exclusion criteria were deliberate hypothermia, age <18 years, or death on day of admission. Separately, to validate the accuracy of hypothermia coding, we reviewed the hospital charts of all University of Louisville Hospital patients with hypothermia whose data were submitted to UHC.

      Results

      All patients from UHC with a code for hypothermia were indeed unintentionally hypothermic. Hypothermic patients undergoing elective operations experienced a 4-fold increase in mortality (17.0% vs 4.0%; P < .001) and a doubled complication rate (26.3% vs 13.9%; P < .001), in which sepsis and stroke increased the most. Several independent risk factors for hypothermia were amenable to preoperative improvement: anemia, chronic renal impairment, and unintended weight loss. Severity of illness on admission, age >65 years, male sex, and neurologic disorders also were risk factors.

      Conclusion

      Hypothermia is associated with an increased rate of mortality and complications. Preventive treatment of these risk factors before operation and aggressive warming measures in the “at risk” population may decrease hypothermia-related morbidity and mortality in elective operations. Randomized-controlled trials should be conducted to evaluate the impact of aggressive warming measures in the at-risk population.
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      References

        • Bratzler D.W.
        • Hunt D.R.
        The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery.
        Clin Infect Dis. 2006; 43: 322-330
        • Polk Jr., H.C.
        • Lopez-Mayor J.F.
        Postoperative wound infection: a prospective study of determinant factors and prevention.
        Surgery. 1969; 66: 97-103
        • Hendren S.
        • Fritze D.
        • Banerjee M.
        • Kubus J.
        • Cleary R.K.
        • Englesbe M.J.
        • et al.
        Antibiotic choice is independently associated with risk of surgical site infection after colectomy: a population-based cohort study.
        Ann Surg. 2013; 257: 469-475
        • Platt R.
        • Zaleznik D.F.
        • Hopkins C.C.
        • Dellinger E.P.
        • Karchmer A.W.
        • Bryan C.S.
        • et al.
        Perioperative antibiotic prophylaxis for herniorrhaphy and breast surgery.
        N Engl J Med. 1990; 322: 153-160
        • Rowe-Jones D.C.
        • Peel A.L.
        • Kingston R.D.
        • Shaw J.F.
        • Teasdale C.
        • Cole D.S.
        Single dose cefotaxime plus metronidazole versus three dose cefuroxime plus metronidazole as prophylaxis against wound infection in colorectal surgery: multicentre prospective randomised study.
        BMJ. 1990; 300: 18-22
        • Kurz A.
        • Sessler D.I.
        • Lenhardt R.
        Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.
        N Engl J Med. 1996; 334: 1209-1215
        • Flores-Maldonado A.
        • Medina-Escobedo C.E.
        • Rios-Rodriguez H.M.
        • Fernandez-Dominguez R.
        Mild perioperative hypothermia and the risk of wound infection.
        Arch Med Res. 2001; 32: 227-231
        • Barone J.E.
        • Tucker J.B.
        • Cecere J.
        • Yoon M.Y.
        • Reinhard E.
        • Blabey Jr., R.G.
        • et al.
        Hypothermia does not result in more complications after colon surgery.
        Am Surg. 1999; 65: 356-359
        • Lehtinen S.J.
        • Onicescu G.
        • Kuhn K.M.
        • Cole D.J.
        • Esnaola N.F.
        Normothermia to prevent surgical site infections after gastrointestinal surgery: holy grail or false idol?.
        Ann Surg. 2010; 252: 696-704
        • Mahid S.S.
        • Polk Jr., H.C.
        • Lewis J.N.
        • Turina M.
        Opportunities for improved performance in surgical specialty practice.
        Ann Surg. 2008; 247: 380-388
        • Laupland K.B.
        • Zahar J.R.
        • Adrie C.
        • Schwebel C.
        • Goldgran-Toledano D.
        • Azoulay E.
        • et al.
        Determinants of temperature abnormalities and influence on outcome of critical illness.
        Crit Care Med. 2012; 40: 145-151
        • Mehta O.H.
        • Barclay K.L.
        Perioperative hypothermia in patients undergoing major colorectal surgery..
        ANZ J Surg. 2014; 84: 550-555
        • Frank S.M.
        • Fleisher L.A.
        • Breslow M.J.
        • Higgins M.S.
        • Olson K.F.
        • Kelly S.
        • et al.
        Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial.
        JAMA. 1997; 277: 1127-1134
        • White R.H.
        • Sadeghi B.
        • Tancredi D.J.
        • Zrelak P.
        • Cuny J.
        • Sama P.
        • et al.
        How valid is the ICD-9-CM based AHRQ patient safety indicator for postoperative venous thromboembolism?.
        Med Care. 2009; 47: 1237-1243
        • Elixhauser A.
        • Steiner C.
        • Harris D.R.
        • Coffey R.M.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
      1. MD APR DRG-software. Available from http://solutions.3m.com/wps/portal/3M/en_US/Health-Information-Systems/HIS/Products-and-Services/Products-List-A-Z/APR-DRG-Software/. Accessed November 16, 2013.

      2. Inpatient Quality Indicators Technical Specifications - Version 4.5, May 2013. Available from http://qualityindicators.ahrq.gov/Modules/IQI_TechSpec.aspx. Accessed November 16, 2013.

      3. Patient Safety Indicators Technical Specifications - Version 4.5, May 2013. Available from http://qualityindicators.ahrq.gov/Modules/PSI_TechSpec.aspx. Accessed November 16, 2013.

        • Beilman G.J.
        • Blondet J.J.
        • Nelson T.R.
        • Nathens A.B.
        • Moore F.A.
        • Rhee P.
        • et al.
        Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality.
        Ann Surg. 2009; 249: 845-850
        • Melton G.B.
        • Vogel J.D.
        • Swenson B.R.
        • Remzi F.H.
        • Rothenberger D.A.
        • Wick E.C.
        Continuous intraoperative temperature measurement and surgical site infection risk: analysis of anesthesia information system data in 1008 colorectal procedures.
        Ann Surg. 2013; 258: 606-613
        • Ireland A.J.
        • Pathi V.L.
        • Crawford R.
        • Colquhoun I.W.
        Back from the dead: extracorporeal rewarming of severe accidental hypothermia victims in accident and emergency.
        J Accid Emerg Med. 1997; 14: 255-257
        • Palm K.
        • Apodaca A.
        • Spencer D.
        • Costanzo G.
        • Bailey J.
        • Blackbourne L.H.
        • et al.
        Evaluation of military trauma system practices related to damage-control resuscitation.
        J Trauma Acute Care Surg. 2012; 73: S459-S464
        • De Witte J.L.
        • Demeyer C.
        • Vandemaele E.
        Resistive-heating or forced-air warming for the prevention of redistribution hypothermia.
        Anesth Analg. 2010; 110: 829-833
        • Kwon S.
        • Thompson R.
        • Dellinger P.
        • Yanez D.
        • Farrohki E.
        • Flum D.
        Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program.
        Ann Surg. 2013; 257: 8-14
        • Adams A.L.
        • Paxton E.W.
        • Wang J.Q.
        • Johnson E.S.
        • Bayliss E.A.
        • Ferrara A.
        • et al.
        Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009.
        J Bone Joint Surg Am. 2013; 95: 481-487
        • Kim P.
        • Taghon T.
        • Fetzer M.
        • Tobias J.D.
        Perioperative hypothermia in the pediatric population: a quality improvement project.
        Am J Med Qual. 2013; 28: 400-406
        • Brandt S.
        • Oguz R.
        • Huttner H.
        • Waglechner G.
        • Chiari A.
        • Greif R.
        • et al.
        Resistive-polymer versus forced-air warming: comparable efficacy in orthopedic patients.
        Anesth Analg. 2010; 110: 834-838
        • Fanelli A.
        • Danelli G.
        • Ghisi D.
        • Ortu A.
        • Moschini E.
        • Fanelli G.
        The efficacy of a resistive heating under-patient blanket versus a forced-air warming system: a randomized controlled trial.
        Anesth Analg. 2009; 108: 199-201
        • Perez-Protto S.
        • Sessler D.I.
        • Reynolds L.F.
        • Bakri M.H.
        • Mascha E.
        • Cywinski J.
        • et al.
        Circulating-water garment or the combination of a circulating-water mattress and forced-air cover to maintain core temperature during major upper-abdominal surgery.
        Br J Anaesth. 2010; 105: 466-470
        • Hasegawa K.
        • Negishi C.
        • Nakagawa F.
        • Ozaki M.
        Core temperatures during major abdominal surgery in patients warmed with new circulating-water garment, forced-air warming, or carbon-fiber resistive-heating system.
        J Anesth. 2012; 26: 168-173
        • Frey J.M.
        • Janson M.
        • Svanfeldt M.
        • Svenarud P.K.
        • van der Linden J.A.
        Local insufflation of warm humidified CO(2)increases open wound and core temperature during open colon surgery: a randomized clinical trial.
        Anesth Analg. 2012; 115: 1204-1211
        • Inaba K.
        • Berg R.
        • Barmparas G.
        • Rhee P.
        • Jurkovich G.J.
        • Recinos G.
        • et al.
        Prospective evaluation of ambient operating room temperature on the core temperature of injured patients undergoing emergent surgery.
        J Trauma Acute Care Surg. 2012; 73: 1478-1483
        • Andersson A.E.
        • Bergh I.
        • Karlsson J.
        • Eriksson B.I.
        • Nilsson K.
        The application of evidence-based measures to reduce surgical site infections during orthopedic surgery—report of a single-center experience in Sweden.
        Patient Saf Surg. 2012; 6: 11
        • Fairchild K.D.
        • Singh I.S.
        • Patel S.
        • Drysdale B.E.
        • Viscardi R.M.
        • Hester L.
        • et al.
        Hypothermia prolongs activation of NF-kappaB and augments generation of inflammatory cytokines.
        Am J Physiol Cell Physiol. 2004; 287: C422-C431
        • Fairchild K.D.
        • Viscardi R.M.
        • Hester L.
        • Singh I.S.
        • Hasday J.D.
        Effects of hypothermia and hyperthermia on cytokine production by cultured human mononuclear phagocytes from adults and newborns.
        J Interferon Cytokine Res. 2000; 20: 1049-1055
        • Matsui T.
        • Ishikawa T.
        • Takeuchi H.
        • Tsukahara M.
        • Maekawa T.
        Mild hypothermia inhibits IL-10 production in peripheral blood mononuclear cells.
        Acta Anaesthesiol Scand. 2004; 48: 205-210
        • Qadan M.
        • Gardner S.A.
        • Vitale D.S.
        • Lominadze D.
        • Joshua I.G.
        • Polk Jr., H.C.
        Hypothermia and surgery: immunologic mechanisms for current practice.
        Ann Surg. 2009; 250: 134-140
        • Hershman M.J.
        • Cheadle W.G.
        • Wellhausen S.R.
        • Davidson P.F.
        • Polk Jr., H.C.
        Monocyte HLA-DR antigen expression characterizes clinical outcome in the trauma patient.
        Br J Surg. 1990; 77: 204-207
        • Docke W.D.
        • Randow F.
        • Syrbe U.
        • Krausch D.
        • Asadullah K.
        • Reinke P.
        • et al.
        Monocyte deactivation in septic patients: restoration by IFN-gamma treatment.
        Nat Med. 1997; 3: 678-681
        • Venet F.
        • Tissot S.
        • Debard A.L.
        • Faudot C.
        • Crampe C.
        • Pachot A.
        • et al.
        Decreased monocyte human leukocyte antigen-DR expression after severe burn injury: Correlation with severity and secondary septic shock.
        Crit Care Med. 2007; 35: 1910-1917
        • Akriotis V.
        • Biggar W.D.
        The effects of hypothermia on neutrophil function in vitro.
        J Leukoc Biol. 1985; 37: 51-61
        • Alexander H.R.
        • Sheppard B.C.
        • Jensen J.C.
        • Langstein H.N.
        • Buresh C.M.
        • Venzon D.
        • et al.
        Treatment with recombinant human tumor necrosis factor-alpha protects rats against the lethality, hypotension, and hypothermia of gram-negative sepsis.
        J Clin Invest. 1991; 88: 34-39
        • Melling A.C.
        • Ali B.
        • Scott E.M.
        • Leaper D.J.
        Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial.
        Lancet. 2001; 358: 876-880