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Anesth Analg 2002;94:215-220
© 2002 International Anesthesia Research Society

GENERAL ARTICLES

What are the Most Important Risk Factors for a Patient’s Developing Intraoperative Hypothermia?

Alex Macario, MD MBA*, and Franklin Dexter, MD PhD{dagger}

*Department of Anesthesia, Stanford University, Stanford, California; and {dagger}Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa

Address correspondence and reprint requests to Alex Macario, MD, MBA, Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305-5640. Address e-mail to amaca{at}stanford.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
Anesthesiologists attempt to maintain perioperative normothermia for surgical patients. We surveyed clinical anesthesiologists and physician researchers and asked them to prioritize risk factors for a patient to develop intraoperative hypothermia. The questionnaire included 41 factors associated with changes in patient temperature identified during a computerized literature search. We asked respondents to estimate the relative importance of each risk factor on a 10-point scale. The survey was mailed to two groups: 1) 180 anesthesiologists (n = 84 respondents) randomly selected from the 1999 American Society of Anesthesiologists Members Directory and to 2) 24 physician researchers (n = 12 respondents) in thermoregulation. Researchers rated the following to be the most important risk factors for hypothermia (in sequence): neonates, a low ambient operating room temperature, burn injuries, general anesthesia with neuraxial anesthesia, geriatric patients, low temperature of the patient before induction, a thin body type, and large blood loss. The results for the clinician group were similar, because the median differences between the groups’ results were two or fewer units for all items. The risk factors identified to be most important can now be further evaluated in clinical trials to develop a multivariate predictive tool for calculating a patient’s a priori risk for developing hypothermia.

IMPLICATIONS: Surveys of clinicians and physician researchers identified what they consider to be the most important risk factors for perioperative hypothermia (e.g., neonates, a low ambient operating room temperature, burn patients, and general anesthesia with neuraxial anesthesia).


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Surgical patients may be admitted to the postanesthesia care unit with inadvertent hypothermia (i.e., core temperatures <36°C) (1). Mild perioperative core hypothermia may increase the risk of wound infection (2), bleeding (3,4), cardiac complications (5), and a prolonged postanesthesia care unit stay (6). In addition, the quality of a patient’s recovery may also suffer because of shivering and thermal discomfort (7,8).

The rapid decrease in core temperature in the first hour after the induction of general anesthesia is caused by redistribution of heat within the body away from the core and toward the peripheral thermal compartment (9). However, currently, there are no algorithms (or clinical risk-stratifying tools) to help anesthesiologists determine the appropriate heat-conserving measures to use on a particular patient. For example, should a patient scheduled to undergo a hysterectomy receive warmed IV fluids prophylactically? Should a patient undergoing hip replacement surgery receive forced air warming starting at the induction of general anesthesia, or should a cotton blanket be placed on the patient initially (10)?

As a first step in developing a clinical risk-stratifying tool to help determine appropriate heat-conserving measures, we aimed to prioritize risk factors for a patient to develop intraoperative hypothermia. For example, is the size of the incision more or less predictive of whether the patient will develop intraoperative hypothermia than the temperature of the operating room (OR) during surgery?

We hypothesized, on the basis of review of the literature, that the most important risk factors for a patient’s developing intraoperative hypothermia were the thermal status of the patient before surgery (11,12), the size and age of the patient (13,14) (e.g., a newborn versus an obese adult), the ambient OR temperature (15), the size of the surgical incision (16,17), and the presence of neuropathy (18). The goal of this study was to prioritize risk factors for a patient developing intraoperative hypothermia during routine surgical cases, by surveying clinical practitioners. We also surveyed physician researchers who have published studies on temperature regulation to determine whether there were any differences in their expectations compared with the rankings provided by surveyed clinicians without published research in temperature regulation. The risk factors specifically identified as important can then be studied in clinical trials to quantify the relative importance of each risk factor and develop a multivariate tool to predict a patient’s risk for developing hypothermia.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
The Stanford University Medical Center Human Subjects Committee approved this study. Content validity refers to the capacity of a questionnaire to measure all the dimensions of the phenomenon under investigation (e.g., risk factors for hypothermia) or the degree to which an empirical measurement reflects and includes the specific areas of the problem being studied. We therefore followed published guidelines in compiling studies on perioperative temperature regulation (19,20). We searched electronically for thermoregulation articles by using MEDLINE, limiting consideration to English-language journals published between 1986 and June 2000 with studies conducted on human subjects. The phrase "hypothermia and thermoregulation" was entered separately, both as a Medical Subject Heading and as text words.

The contents of all 81 abstracts and full-text articles obtained from our literature search were read in full (a sample of these studies is included in References) to identify validated factors associated with patient temperature. In addition, a manual search, which was performed by screening citation lists in review articles, yielded another 48 articles.

The validity of a survey instrument may be defined as the extent to which differences in observed scale scores reflect true differences among objects on the characteristic being measured, rather than systematic or random error. To assess content validity, sometimes called face validity, the researcher examines whether the scale items adequately cover the entire domain of the construct being measured. Because the comprehensive list of 41 risk factors in our survey instrument associated with the development of intraoperative hypothermia was constructed from the articles obtained from the literature search, we believe that the questionnaire has content validity.

During a pretest phase, this list was examined by four senior, board-certified anesthesiologists in the Department of Anesthesiology, Stanford University, as well as by a convenience sample of five local community practitioners. This pretest phase helped to ensure that the questions were properly interpreted, that significant risk factors were not excluded, and that the survey could be completed within a short period of time (i.e., 10–12 min). The final complete survey used for this study is available from the authors.

A sample of the text on the first page of the questionnaire reads as follows. "The purpose of this study is to quantify the relative importance of risk factors for a patient developing hypothermia (core T < 36.0) in the OR, assuming no temperature preserving/increasing interventions are used. Some of the factors listed may be inter-related. For now assume that they are independent."

Although the exact definition of intraoperative normothermia has been the subject of debate, we choose to use <36°C as the definition of hypothermia (21). Normal body temperature averages 37°C with a normal circadian body temperature variation, equaling approximately 1°C (22,23).

We asked respondents to "estimate the relative importance (which risk factor is more important compared to others) on a scale of 1–10, with a ‘1’ corresponding to ‘not likely to be important in causing hypothermia’ and a ‘10’ corresponding to ‘most likely to be important in causing hypothermia.’ The more points the more important."

The survey was mailed to two groups: 1) 180 anesthesiologists randomly selected from the 1999 American Society of Anesthesiologists Members Directory and 2) 24 physician researchers in thermoregulation. The researchers were selected from the list of authors with "MD" after their name and one or more studies identified during the literature search described previously. A second mailing was performed for those subjects who did not respond to the first mailing.

"Reliability" refers to the extent to which a scale produces consistent results if repeated measurements are made (24). Systematic sources of error do not have an adverse effect on reliability because they affect the measurement in a constant way and do not lead to inconsistency. In contrast, random error produces inconsistency, leading to lower reliability. We used the test-retest approach for assessing reliability. In test-retest reliability, respondents are administered identical sets of scale items at two different times under as nearly equivalent conditions as possible. We asked 17 of the respondents to complete an identical questionnaire a second time, at least 3 days after the original questionnaire.

Because the data were not normally distributed, the results are presented on the basis of medians (quartile deviation). Confidence intervals for the shifts in the two groups’ statistical distributions of responses for each item were calculated by using the Hodges-Lehmann method (StatXact-4, Cytel Software Corp., Cambridge, MA).


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
Eighty-two of 162 clinicians completed the survey (eight of these questionnaires were returned after the second mailing). Sixteen other mailed questionnaires were returned because of an incorrect mailing address. Two subjects returned the questionnaire to us by mail, indicating that they were retired. Twelve of 24 researchers completed the survey (Table 1).


View this table:
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  		Table 1. Demographics of Respondents
 
Reliability and validity of the results are supported by two findings. First, the patient’s being hypothermic before surgery was listed by all 94 respondents as a more important risk factor for hypothermia than the patient’s being normothermic. This suggests that respondents understood what was being asked of them. Second, the questionnaire proved to have test-retest reliability because 40 of 41 items had changes of two or fewer units for all 17 subjects asked to complete the survey twice.

Researchers and clinicians rated the following to be the most important risk factors for hypothermia (in sequence): neonates, a low ambient OR temperature, burn patients, general anesthesia with neuraxial anesthesia, geriatric patients, low temperature of the patient before induction, a thin body type, and large blood loss (Table 2).


View this table:
[in this window]
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  		Table 2. Rankings of Risk Factors by Physician Researchers and Comparisons with Other Clinicians
 
For all 41 items, the median differences between the answers for the Clinician group and the Researcher group were two or fewer units (Table 2). All 95% confidence intervals were three or fewer units.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
Whereas a literature search on hypothermia research yields a list of risk factors, there are few data on their relative importance. We found that neonates, a low ambient OR temperature, burn patients, and general anesthesia with neuraxial anesthesia were believed to be (by researchers and clinicians) the four factors most likely to result in hypothermia.

The risk factors identified in this study could be used to establish clinical studies to quantify the relative importance of each risk factor. These clinical studies are continuing. As an example, in a study of only patients receiving spinal anesthesia, a high level of spinal blockade and increasing age were predictors of hypothermia (25). It is interesting that for this group receiving spinal anesthesia, the duration of surgery, the ambient OR temperature, and body habitus were not predictors of hypothermia.

A next step would be to quantify how much more or less important one risk factor is than another in a wider variety of cases. Then, a multivariate predictive tool could be developed to calculate a patient’s a priori risk for developing hypothermia, if preventive measures are not taken. Such tools have been developed to assess the risk of death from heart failure after coronary artery bypass graft surgery, for example (26). Finally, recommendations ranging in cost and efficacy for appropriate hypothermia prophylaxis can be provided to practitioners (e.g., via a pocket-sized card or an automated anesthesia information system). However, whether this type of clinical decision support improves perioperative outcomes also requires rigorous study.

The rankings presented here are based on researchers’ interpretation of studies’ findings. The fact that clinicians’ ratings were the same as those by researchers points to the validity of the study’s findings, clinicians reading the results of scientific studies, clinical experience helping predict scientific findings, or a combination of these. That clinical experience has predicted scientific findings is likely to hold because temperature can be measured easily and routinely in patients undergoing general anesthesia.

Intraoperative core hypothermia develops in three phases: core-to-peripheral redistribution of body heat, a slow linear decrease in core temperature caused by heat loss exceeding metabolic heat production, and core temperature plateau as vasoconstriction constrains heat in the core compartment. The highest rated item was neonates. The head constitutes a larger fraction of the total surface area in neonates. Heat loss from the head by neonates may be greater than in adults because the skull and scalp are thin, allowing loss of heat delivered to the brain (27). Redistribution of body heat that is most prominent in the first hour of anesthesia contributes less to hypothermia in infants (than in adults) because their extremities are small compared with their trunk and head (also resulting in a large surface area to body weight ratio) (28).

The second highest rated item was a low ambient OR temperature. At OR temperatures <21°C, hypothermia often occurs, especially during general anesthesia (29). At 23°C, hypothermia occurs less often. In a study of 40 patients receiving general anesthesia for orthopedic surgery, an ambient OR temperature near 26°C (79°F) was effective in preventing core hypothermia during general anesthesia regardless of patient age (30).

Another highly rated item was general anesthesia with neuraxial anesthesia. Because both general and regional anesthetics impair the thermoregulatory system, anesthetized patients become relatively poikilothermic, whereby core temperature drifts toward ambient temperature (31). Patients receiving epidural (32,33) or spinal anesthesia (34,35) have impaired thermoregulation because of vasodilation in the lower extremities and an impaired hypothalamic response with decreased shivering and vasoconstriction thresholds (36,37). This effect is proportional to the number of dermatomes blocked (38). General anesthesia inhibits the shivering that might otherwise increase heat production during neuraxial anesthesia.

Three other risk factors deemed important by both researchers and clinicians were patient age (i.e., geriatric patients), low temperature of the patient before induction, and a thin body habitus. Geriatric patients thermoregulate via vasoconstriction and shivering less effectively than younger patients, both in the presence and absence of anesthesia (39,40). Patient temperature before induction refers to peripheral tissue heat content and core-to-peripheral tissue temperature gradient, which determines the magnitude of redistribution. The effects of body morphology have also been reasonably well evaluated. In 40 patients undergoing elective colon surgery, the amount of redistribution hypothermia was inversely proportional to the percentage of body fat and the ratio of weight to surface area (41).

There are several potential limitations to the study. As with any survey-based study, the results may be affected by a variety of biases. The overall response rate was 51%. We did not detect differences in responses from the group that returned the survey after the first mailing as compared with the responses obtained after the second mailing. In addition, respondents were asked to list other risk factors that should be included that were not on the original questionnaire. No one risk factor was suggested by more than two respondents. Thus, it seems that our study did not miss any important risk factors. The generalizability of these rankings to all North American anesthesia providers is supported because the subject population was composed of practitioners from 21 states in the United States. However, it is possible that the opinion in other parts of the world could differ.

We conclude that neonates, a low ambient OR temperature, burn patients, general anesthesia with neuraxial anesthesia, geriatric patients, low patient temperature before induction, a thin body type, and large blood loss (in that order) were rated as most likely to be important in causing hypothermia. No significant differences were detected in responses between researchers and clinicians.


   Acknowledgments
 
Funded in part by Augustine Medical, Inc., Eden Prairie, MN. The funding organization did not participate in the design, conduct, interpretation, analysis, or submission of the study.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

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Accepted for publication August 8, 2001.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press