PATIENT WARMING


to approximately 4 to 5 days through the use of such programmes. NICE acknowledged that it is difficult to demonstrate how a single technology, such as HumiGard, affects total length of stay but the committee accepted that interventions which reduce surgical site infections would be beneficial. NICE concluded that there is good evidence to support the use of measures to prevent hypothermia during abdominal surgery and that, in this regard, HumiGard shows promise. However, it considered that there is insufficient evidence to demonstrate that HumiGard has a substantial effect on reducing adverse outcomes for patients having abdominal surgery. The committee concluded that the cost consequences of using HumiGard in abdominal surgery are very uncertain, and that further research is needed on resource use.


Nutrition and hypothermia


The answer to tackling hypothermia lies in a combination of external heating methodologies and therapies that target heat loss from within. But there are some new approaches on the horizon and, if proven, these could add to our understanding of how to optimise the patient’s temperature during surgery. In particular, there is some interesting research emerging into nutrition and hypothermia, which hypothesises that targeting the patient’s metabolism could prove beneficial. The theory put forward is that the administration of intravenous nutrients during the perioperative period may reduce heat loss by increasing metabolism, thereby increasing heat production. A Cochrane review21


considered the


evidence in support of this hypothesis. The authors included 14 trials, which compared intravenous administration of amino acids to a control (usually saline solution or Ringer’s lactate). The remaining trial compared intravenous administration of fructose versus a control. Some trials showed that higher temperatures were associated with amino acids, but not all trials reported statistically significant results, and some trials reported the opposite result, where the amino acid group had a lower core temperature than the control group. It was possible to conduct meta-analysis for six studies that provided data relating to the end of surgery. Amino acids led to a statistically significant increase in core temperature in comparison to those receiving control. Three trials reported shivering as an outcome. Meta-analysis did not show a clear effect, and so it is uncertain whether amino acids reduce the risk of shivering.


The authors concluded that: “Intravenous amino acids may keep participants up to a half-degree C warmer than the control. This difference was statistically significant at the end of surgery, but not at other time points.” The authors added that the clinical


importance of this finding remains unclear. It is also unclear whether amino acids have any effect on the risk of shivering and if


64 I WWW.CLINICALSERVICESJOURNAL.COM


The answer to tackling hypothermia lies in a combination of external heating methodologies and therapies that target heat loss from within


intravenous nutrients confer any other benefits or harms, as high-quality data about these outcomes are lacking. There is a need for further research into this area, but the study findings give some cause to be optimistic about the role of amino acids and nutrition in tackling perioperative hypothermia.


Conclusion


We know that inadvertent perioperative hypothermia leads to poorer outcomes. Indeed, NICE states that arriving at the theatre suite with a temperature below 36˚C is a ‘critical incident’ that should be reported. Yet, half of patients undergoing surgery experience hypothermia. We urgently need to understand why something so preventable continues to be commonplace in hospital theatres. Getting the basics right, is the first step towards improved outcomes and reducing harm.


References


1 Godfrey, E, Study shows hypothermia occurs during surgery in around half of patients, Euroanaesthesia congress in Berlin, in 2015, https://www.eurekalert.org/pub_releases/2015- 05/eso-ssh052715.php


2 NICE Clinical guideline [CG65], Hypothermia: prevention and management in adults having surgery, Published date: April 2008, Last updated: December 2016


3 Steelman VM et al, Warming of Irrigation Fluids for Prevention of Perioperative Hypothermia During Arthroscopy: A Systematic Review and Meta- analysis, Arthroscopy. 2018 Mar;34(3):930-942.e2. doi: 10.1016/j.arthro.2017.09.024. Epub 2017 Dec


4 NICE Medical technologies guidance [MTG31], HumiGard for preventing inadvertent perioperative hypothermia, February 2017


5 Sajid, M. S., Mallick, A. S., Rimpel, J., Bokari, S., Cheek, E. & Baig, M. 2008. Effect of heated and humidified carbon dioxide on patients after laparoscopic procedures: A metaanalysis. Surgical Laparoscopy Endoscopy Percutaneous Techniques, 18(6):539-546.


6 Davey, AK, et al, 2013. The Effects of Insufflation Conditions on Rat Mesothelium. International Journal of Inflammation, doi: 10.1155/2013/816283


7 Frey, JM, et al, 2012. Local insufflation of warm, humidified CO2


increases open-wound and


core temperature during open colon surgery: A randomized clinical trial. Anesthesia Analgesia. 115(5): 1204-1211.


8 Marshall J, et al. Insufflation of warm, humidified CO2


during open abdominal surgery reduces loss of peritoneal mesothelium and increases sub- peritoneal tissue oxygen tension in a rat model. Colorectal Disease. 2014;16 (Suppl. 2):4–37.


9 Kurz, A; Sessler, DI, & Lenhardt, R. 1996. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. New England Journal of Medicine, 334:1209–1215


10 Noor, N, et al, 2015. Use of warmed humidified insufflation carbon dioxide to reduce surgical site infections in laparoscopic colorectal surgery: a cohort study. Gut. 64:A545 doi:10.1136/gutjnl- 2015-309861.1195


11 NICE, Costing statement: Surgical site infection: prevention and treatment of surgical site infection, 2008.


12 NICE, (2013) NICE support for commissioning for surgical site infection.


13 Mason, SE, et al, 2015. Cost-effectiveness of warm humidified CO2


to reduce surgical site infections in


laparoscopic colorectal surgery: a cohort study. Gut. 64:A556 doi:10.1136/gutjnl-2015-309861.1220.


14 Binda, MM; Corona, R; Amant, F, & Koninckx, PR. 2014. Conditioning of the abdominal cavity reduces tumour implantation in a laparoscopic mouse model. Surgery Today, 44(7):1328-35. doi: 10.1007/s00595-014-0832-5.


15 Carpinteri, S, et al, 2015. Peritoneal tumorigenesis and inflammation are ameliorated by humidified- warm carbon dioxide insufflation in the mouse. Annals of Surgical Oncology. doi: 10.1245/s10434- 015-4508-1


16 Herrmann, A and De Wilde, RL, Insufflation with Humidified and Heated Carbon Dioxide in Short-Term Laparoscopy: A Double-Blinded Randomized Controlled Trial, Biomed Res Int. 2015; 2015: 412618. Published online 2015 Jan 28. doi: 10.1155/2015/412618


17 Manwaring JM, Readman E, Maher PJ, The effect of heated humidified carbon dioxide on postoperative pain, core temperature, and recovery times in patients having laparoscopic surgery: a randomized controlled trial. Journal of Minimally Invasive Gynecology. 2008;15(2):161–165. doi: 10.1016/j.jmig.2007.09.007.


18 Sammour T, Kahokehr A, Hill AG. Independent testing of the Fisher & Paykel Healthcare MR860 Laparoscopic Humidification System. Minimally Invasive Therapy and Allied Technologies. 2010;19(4):219–223. doi: 10.3109/ 13645701003644475.


19 Yu T-C, et al. Warm, humidified carbon dioxide gas insufflation for laparoscopic appendicectomy in children: a double-blinded randomized controlled trial. Annals of Surgery. 2013;257(1):44–53. doi: 10.1097/sla.0b013e31825f0721.


20 Mason, SE, et al, Postoperative hypothermia and surgical site infection following peritoneal insufflation with warm, humidified carbon dioxide during laparoscopic colorectal surgery: a cohort study with cost-effectiveness analysis. Surg Endosc. 2017 Apr;31(4):1923-1929. doi: 10.1007/s00464-016-5195-0. Epub 2016 Oct 12.


21 Warttig, S, et al, Intravenous nutrients for preventing inadvertent perioperative hypothermia in adults. Cochrane Database Syst Rev. 2016 Nov 22;11: CD009906.


SEPTEMBER 2018


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80