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Evid Based Nurs 10:114 doi:10.1136/ebn.10.4.114
  • Treatment

Systemic warming before, during, and after major abdominal surgery reduced postoperative complications more than warming during surgery only


 
 Q Does systemic warming before, during, and after major abdominal surgery reduce postoperative morbidity more than warming during surgery only?

METHODS

GraphicDesign:

randomised controlled trial.

GraphicAllocation:

{concealed}.*

GraphicBlinding:

blinded (healthcare providers and {data collectors}*).

GraphicFollow-up period:

6–8 weeks after surgery.

GraphicSetting:

a hospital in the UK.

GraphicPatients:

103 adults >18 years of age (age range 20–88 y, 51% men) who were having major open abdominal surgery, mostly for colorectal cancer (69%). Exclusion criteria were laparoscopic procedures; use of corticosteroids or immunosuppressive drugs 4 weeks before surgery; recent fever or infection; serious malnutrition; and bowel obstruction.

GraphicIntervention:

all patients were placed on an Inditherm® warming mattress (Inditherm, Rotherham, UK) 2 hours before transfer to the operating theatre. 47 patients were allocated to the perioperative warming group, and the mattress was turned on to 40°C 2 hours before, during, and up to 2 hours after surgery. 56 patients were allocated to the control group, and the mattress was switched off. All patients were systemically warmed during surgery using a forced-air warming device (Bair Hugger®, Arizant Healthcare, Eden Prairie, MN, USA) set at 40°C and with a fluid warmer (Ranger® Blood/Fluid Warming System, Arizant Healthcare, Eden Prairie, MN, USA).

GraphicOutcomes:

included blood loss, need for blood transfusion, postoperative complications (surgical site infection, chest infections, ileus, urinary tract infections, pelvic collection, cardiac complications, Clostridium difficile diarrhoea, and pressure ulcers), and length of hospital stay.

GraphicPatient follow-up:

100% (intention to treat analysis).

MAIN RESULTS

Patients in the warming group had less blood loss than those in the control group (200 v 400 ml, p = 0.01); the number requiring transfusions did not differ (table). Fewer patients in the warming group had complications (table). The groups did not differ for length of hospital stay (11 v 9 d, p = 0.22) or surgical site infection (table).

Systemic warming before, during, and after major abdominal surgery v warming during surgery only (control)*

CONCLUSION

Systemic warming before, during, and after elective major abdominal surgery reduced blood loss and postoperative complications more than warming during surgery only.

Commentary

  1. Eileen M Scott, RGN, PhD
  1. University of Durham, Stockton-on-Tees, UK

      Inadvertent perioperative hypothermia is a recognised complication of anaesthesia, when normal temperature regulation is inhibited; it is not unusual for a patient’s core temperature to drop to <35°C during surgery. It is now accepted that episodes of inadvertent hypothermia during surgery can result in serious postoperative complications, such as cardiac arrhythmias, increased blood loss, wound infections, pressure ulcers, and increased morbidity and mortality.1 The emphasis should be on prevention of hypothermia rather than on treatment.

      Intraoperative warming is best practice for many surgical patients, particularly those having major abdominal surgery. Wong et al assessed the effects of supplemental perioperative warming in addition to routine intraoperative forced-air warming that was provided to all study patients. Patients were followed up for 6–8 weeks after surgery, which is a realistic time frame for assessing postoperative complications, particularly wound infection. Patients who had supplemental warming had lower rates of complications than those who did not; they also had lower rates of wound infections and blood transfusions, although these differences were not statistically significant. The inability to show differences in wound infections or blood transfusions may be because of the relative infrequency of such events and the study being too small to detect such differences in isolation.

      Intraoperative warming is an important issue with increasing relevance. It has led to the UK Department of Health commissioning the development of a clinical guideline on the topic.2 It is expected that this guidance, which will address both clinical and cost-effectiveness, will be published in April 2008. The study by Wong et al is therefore a useful and timely addition to the evidence base.

      References

      Footnotes

      • * Information provided by author.

      • For correspondence: MrP F Wong, James Cook University Hospital, Middlesbrough, Cleveland, UK. pwong23{at}hotmail.com

      • Source of funding: no external funding.

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