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GENERAL ARTICLES

Aggressive Warming Reduces Blood Loss During Hip Arthroplasty

Marianne Winkler, MD^*, Ozan Akça, MD, Beatrice Birkenberg, MD, Hubert Hetz, MD^*, Thomas Scheck, BS^*, Cem F. Arkiliç, MD^*, Barbara Kabon, MD^*, Elvine Marker, MD^*, Alexander Grübl, MD, Robert Czepan, MD^*, Manfred Greher, MD^*, Veronika Goll, MD^*, Florian Gottsauner-Wolf, MD, Andrea Kurz, MD^§, and Daniel I. Sessler, MD^*,

*Departments of Anesthesia, General Intensive Care and Orthopedics, University of Vienna, Vienna, Austria; and Outcomes Research Institute and the ^TMDepartment of Anesthesiology, University of Louisville, Louisville, Kentucky; the §Department of Anesthesia, Washington University, St. Louis, Missouri; and Ludwig Boltzmann Institute, Vienna, Austria

Address correspondence to Daniel I. Sessler, MD, University of Louisville, Abell Administration Center 217, 323 East Chestnut St., Louisville, KY 40202-3866. Address e-mail to sessler{at}louisville.edu

We evaluated the effects of aggressive warming and maintenance of normothermia on surgical blood loss and allogeneic transfusion requirement. We randomly assigned 150 patients undergoing total hip arthroplasty with spinal anesthesia to aggressive warming (to maintain a tympanic membrane temperature of 36.5°C) or conventional warming (36°C). Autologous and allogeneic blood were given to maintain a priori designated hematocrits. Blood loss was determined by a blinded investigator based on sponge weight and scavenged cells; postoperative loss was determined from drain output. Results were analyzed on an intention-to-treat basis. Average intraoperative core temperatures were warmer in the patients assigned to aggressive warming (36.5° ± 0.3° vs 36.1° ± 0.3°C, P < 0.001). Mean arterial pressure was similar in each group preoperatively, but was greater intraoperatively in the conventionally warmed patients: 86 ± 12 vs 80 ± 9 mm Hg , P < 0.001. Intraoperative blood loss was significantly greater in the conventional warming (618 mL; interquartile range, 480–864 mL) than the aggressive warming group (488 mL; interquartile range, 368–721 mL; P = 0.002), whereas postoperative blood loss did not differ in the two groups. Total blood loss during surgery and over the first two postoperative days was also significantly greater in the conventional warming group (1678 mL; interquartile range, 1366–1965 mL) than in the aggressively warmed group (1,531 mL; interquartile range, 1055–1746 mL, P = 0.031). A total of 40 conventionally warmed patients required 86 units of allogeneic red blood cells, whereas 29 aggressively warmed patients required 62 units (P = 0.051 and 0.061, respectively). We conclude that aggressive intraoperative warming reduces blood loss during hip arthroplasty.

Implications: Aggressive warming better maintained core temperature (36.5° vs 36.1°C) and slightly decreased intraoperative blood pressure. Aggressive warming also decreased blood loss by approximately 200 mL. Aggressive warming may thus, be beneficial in patients undergoing hip arthroplasty.

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