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Anesth Analg 2003;96:826-833
© 2003 International Anesthesia Research Society

CRITICAL CARE AND TRAUMA

Predictor of Core Hypothermia and the Surgical Intensive Care Unit

Suneerat Kongsayreepong, MD*, Crirapha Chaibundit, MD*, Jittika Chadpaibool, MD*, Chulaluk Komoltri, DrPH{dagger}, Suwannee Suraseranivongse, MD MS*, Pudsadee Suwannanonda, BSN*, Em-orn Raksamanee, BSN*, Pensri Noocharoen, BSN*, Aurasa Silapadech, BSN*, Sudta Parakkamodom, BSN*, Chusri Pum-In, BSN{ddagger}, and Lilanuch Sojeoyya, BSN{ddagger}

Department of *Anesthesiology, {dagger}Clinical Epidemiology Unit, and {ddagger}Department of Nursing, Siriraj Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand

Address correspondence and reprint requests to Suneerat Kongsayreepong, MD, Siriraj Hospital, Faculty of Medicine, Mahidol University, Bangkok-10700, Thailand. Address e-mail to sisko{at}mahidol.ac.th or Maneeratja@yahoo.com.


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Inadvertent postoperative core hypothermia is associated with multiple physiological effects, especially in patients admitted to the intensive care unit (ICU). Despite previous reports of the relationship between patient, surgical, and anesthetic factors and immediate postoperative core hypothermia, this information might need to be reconsidered in the light of progress in surgery, anesthetic, and warming techniques. We designed this prospective study of 194 postgeneral surgical patients to assess the incidence, predictive factors, and outcome of core hypothermia (tympanic membrane core temperature [Tc] <36.0°C) at the time of admission to the general ICU in a large tertiary university medical center from December 2000 to March 2001. The following variables were studied: age, sex, body weight, body surface area, preoperative body temperature, ASA physical status, history of diabetic neuropathy, emergency surgery, surgical subspecialty performing surgery, type of surgery, type of anesthesia (general, regional, or combined epidural and general), temperature monitoring, use of a forced air warming technique, amount of fluid and blood replacement, duration of anesthesia, duration of surgery, and the ambient operating room temperature. Other outcomes, i.e., length of ICU stay and mortality, were also assessed. The incidence of core hypothermia was 57.1%, 41.3%, and 28.3% according to the definition of Tc <36.0°C, <35.5°C, and <35.0°C, respectively. Multiple logistic regression showed the following risk factors for core hypothermia: high ASA physical status (odds ratio, 2.87; 95% confidence interval [CI], 0.82–10.03 for ASA II; odds ratio, 8.35; 95% CI, 1.67–41.88 for ASA >II), magnitude of surgical procedure (odds ratio, 6.60; 95% CI, 1.66–26.19 for medium surgery; odds ratio, 22.23; 95% CI, 5.41–91.36 for major surgery), use of combined epidural and general anesthesia (odds ratio, 3.39; 95% CI, 1.05–10.88), and duration of surgery >2 h (odds ratio, 4.50; 95% CI, 1.48–13.68). Not using temperature monitoring seems to be a risk factor as well (odds ratio, 3.00; 95% CI, 0.87–10.12). Significant protective factors against core hypothermia were heavier body weight (odds ratio, 0.94; 95% CI, 0.89–0.98), higher preoperative body temperature (odds ratio, 0.31; 95% CI, 0.15–0.65), and warmer ambient operating room temperature (odds ratio, 0.67; 95% CI, 0.51–0.88). In conclusion, the incidence of core hypothermia (Tc <36.0°C) at the time of admission to the general ICU is still frequent. To reduce the incidence, more efforts and concern should be taken to prevent core hypothermia, especially in the patient with high ASA physical status, undergoing more intensive and lengthy surgery, and using combined epidural and general anesthesia.

IMPLICATIONS: In an effort to decrease the frequent incidence of core hypothermia at the time of admission to the general surgical intensive care unit, this prospective study showed that high ASA physical status, the use of a combined epidural and general anesthesia, surgery lasting longer than 2 h, and extensive surgery were the important risk factors, whereas heavier body weight, higher preoperative body temperature, and warmer ambient operating room temperature were important protective factors.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Inadvertent core hypothermia is often found in the immediate postoperative period (1–3). Several studies have shown that even the presence of a temperature at 1°C–3°C less than normal in the perioperative period is associated with multiple physiological derangement that may lead to adverse outcomes (1–8).

Although not completely uniform among all studies, certain risk factors have been identified to be independently associated with the development of core hypothermia in the perioperative period. These include age (3,9), sex (1,2,10), body weight and body surface area (11), preoperative body temperature (12), history of diabetic neuropathy (13), emergency surgery (1), surgical procedure in which major body cavities or major vessels are exposed (2), anesthetic technique (10), warming method (14), amount of IV replacement (1), temperature of irrigation fluid (15) or insufflated gas (16), duration of anesthesia or surgery (1,2,10), and ambient operating room (OR) temperature (9). As surgery and anesthesia progress and more advanced technology is introduced with the hope of improving outcomes, these procedures may increase operating time, produce more bleeding, require larger incisions, be performed with a complex technique such as endoscopic surgery (10,15,16), or be performed using combined epidural and general anesthesia (17,18). These new techniques may increase the risk of intraoperative or immediate postoperative core hypothermia as patients recover with intact vasomotor tone and start to shiver, which increases oxygen consumption (9), especially in the group of patients admitted to the intensive care unit (ICU) who usually have significant underlying medical problems or have undergone extensive surgery. Whereas effective warming measures, such as the forced air warming technique (14), are available and more information about core hypothermia (19) and evidence of the adverse effects of core hypothermia (1,2,5–8,20,21) have been reported, the incidence of core hypothermia at the time of admission to the general surgical ICU is still frequent and more frequent than in the postanesthesia care unit (1–3,5,22). In an effort to decrease the frequent incidence of core hypothermia, it would be helpful if significant predictive factors could be re-identified and corrected. This will not only help decrease the current frequent incidence of core hypothermia, but may also help prevent unnecessary risks and adverse outcomes. This information may also be used for further study if other important factors can be identified.

The purpose of this study was primarily to estimate the incidence of core hypothermia at the time of admission to the general surgical ICU in patients who underwent noncardiac surgery and to explore the clinical factors associated with core hypothermia.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
After obtaining approval from the Ethical Clearance Committee of the Human Rights Related to Research Involving Human Subjects, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, and written informed consent, this prospective study was performed on 194 postoperative patients who underwent scheduled or emergency noncardiac surgery and were admitted to our general surgical ICU during the period between December 2000 to February 2001.

All temperatures were recorded in degrees Celsius. The ambient OR temperature was measured using the same type of thermocouple room thermometer (after a correlation test) and placed at the same location, close to the patient, and away from any heat-generating equipment. The ambient temperature was recorded every 30 min until the patient left the OR. Core temperature (Tc) was measured by an infrared tympanic membrane thermometer (Genius® Model 3000A, Sherwood Medical Company, St. Louis, MO; with an accuracy of ±0.03°C in the range of 32.2°C–40.6°C) (23–25). This instrument was maintained and calibrated in accordance with the manufacturer’s guidelines. These tympanic membrane temperatures were obtained immediately after surgery, on arrival at the ICU, by two experienced nurses trained to measure tympanic membrane temperatures and tested for inter- and intraobserver reliability. In patients who could not be admitted to the ICU immediately after surgery, these Tc were measured in the postanesthesia care unit instead.

The following clinical variables that might be predictors of Tc at the time of admission to the ICU were carefully recorded before admission to the ICU: age, sex, body weight, body surface area, preoperative body temperature, ASA physical status, history of diabetic neuropathy, emergency or scheduled surgery, magnitude of surgical procedure as major (surgery in which body cavities or major vessels are exposed to ambient temperature such as major abdominal, thoracic, major vascular, thoracic spine surgery with instrumentation, or hip arthroplasty), medium (surgery in which body cavities are exposed to a lesser degree such as appendectomy), and minor surgery (superficial surgery), type of anesthesia, use of temperature monitoring, use of a forced air warming technique, amount of fluid and blood replacement, duration of anesthesia, duration of surgery, and ambient OR temperature.

The primary outcome was core hypothermia at the time of admission to the ICU, whereas the secondary outcomes were length of stay in ICU and mortality (including all deaths during hospitalization for the operation regardless of length of hospital stay).

From a pilot study of 100 subjects, the incidence of core hypothermia (Tc <36.0°C) on admission to ICU was 45%. Therefore, to achieve the primary objective to estimate the incidence of core hypothermia of 45% with a 95% confidence interval (CI) of 38%–52%, a sample of 194 subjects was required. The secondary objective of the study was for exploratory purpose; therefore, no sample size was determined.

The incidence of core hypothermia at the time of admission to the ICU and its 95% CI were calculated by using three different criteria for diagnosing hypothermia, i.e., Tc <36.0°C, Tc <35.5°C, and Tc <35.0°C, respectively (19).

For more precise analysis of the clinical predictors of core hypothermia on admission to ICU, pediatric patients (<=14 yr old) and patients with hyperthermia (Tc >38.5°C) were excluded from the analysis. In determining factors associated with core hypothermia, a cut point of Tc <36.0°C was used to classify patients as hypothermic and Tc >=36.0°C as normothermic because clinical evidence has shown that this level of core hypothermia in the immediate postoperative period for noncardiac surgery was associated with multiple physiological derangement that may lead to adverse outcomes (1). Furthermore, a Tc <36.0°C has been defined as hypothermia in the ICU (26). However, statistical analysis using cutoff points of Tc <35.5°C and Tc <35.0°C was also performed. To assess the relationship between each clinical predictor and core hypothermia, univariate analysis was performed using an unpaired t-test, {chi}2 test, or Fisher’s exact test along with an odds ratio and its 95% CI. Multiple logistic regression analysis was performed to evaluate the effect of each factor on core hypothermia adjusting for the other factors. To identify factors that were different among the four surgical specialties, univariate analysis was performed.

Length of ICU stay was categorized into three groups: 1 day, 2 days, and more than 2 days. To assess factors associated with days in ICU, univariate analysis was first performed using one-way analysis of variance and {chi}2 test. Because of the ordinal nature of length of stay in the ICU, a proportional odds model was fitted to obtain the adjusted odds ratio of each predictor.

Regarding factors related to mortality, there were only 11 deaths; therefore, only univariate analysis was performed. A two-sided significance level of 0.05 was used for all analyses. Quantitative variables are presented as mean ± SD. All analyses were performed using SAS 8.0 (SAS Institute, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Of the 194 patients admitted to the general surgical ICU, the mean (± SD) admission Tc was 35.6°C ± 1.3°C (range, 31.1°C–38.9°C). Incidences of core hypothermia at the time of admission to the ICU according to the definitions of Tc <36.0°C, Tc <35.5°C, and Tc <35.0°C were 57.1% (95% CI, 49.6%–64.3%), 41.3% (95% CI, 34.1%–48.8%), and 28.3% (95% CI, 21.9%–35.4%), respectively. Three patients were admitted with a Tc <33.0°C (31.1°C, 31.2°C, and 32.2°C, respectively).

For the exploratory secondary objective to determine the predictors of core hypothermia, pediatric patients (<=14 yr old) and patients with hyperthermia (Tc >38.5°C) were excluded, leaving 184 patients in this part of the study (Table 1). A cutoff point for core hypothermia of Tc <36.0°C was used. According to univariate analysis (Table 2 and 3), sex, ASA physical status, history of diabetic neuropathy, emergency surgery, general or regional anesthesia, use of a forced air warming technique, and use of temperature monitoring were not predictive of core hypothermia.


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  		Table 1. Patient Baseline Characteristics (n = 184)
 

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  		Table 2. Univariate Analysis of Putative Categorical Predictors of Core Hypothermia (Tc < 36.0°C) at the Time of Admission to the General Surgical ICU
 

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  		Table 3. Univariate Analysis of Putative Continuous Predictors of Core Hypothermia at the Time of Admission to the General Surgical ICU
 
Heavier body weight, larger body surface area (P = 0.0001), increased preoperative body temperature (P < 0.0001), and average ambient temperature during surgery (P = 0.0002) were significant protective factors against core hypothermia. Significant risk factors for hypothermia were the magnitude of surgery (odds ratio, 4.03; 95% CI, 1.33–13.68 for medium surgery; odds ratio, 14.28; 95% CI, 4.88–46.53 for major surgery), use of combined epidural and general anesthesia (odds ratio, 2.33; 95% CI, 1.13–4.80), and duration of surgery longer than 2 h (odds ratio, 2.54; 95% CI, 1.30–4.96). Patient age older than 70 yr (odds ratio, 1.83; 95% CI, 0.77–4.31), duration of anesthesia longer than 2 h (odds ratio, 2.08; 95% CI, 0.99–4.40), and fluid replacement >4000 mL (odds ratio, 1.24; 95% CI, 0.38–4.02) tended to be significant risk factors of core hypothermia.

Table 4 displays the results of the multiple logistic regression analysis. With regard to preoperative factors, significant protective factors against core hypothermia were heavier body weight (odds ratio, 0.94; 95% CI, 0.89–0.98) and higher preoperative body temperature (odds ratio, 0.31; 95% CI, 0.15–0.65). The higher the ASA physical status of the patient, the higher the risk of core hypothermia (odds ratio, 2.87; 95% CI, 0.82–10.03 for ASA II; odds ratio, 8.35; 95% CI, 1.67–41.88 for ASA >II). Patient age older than 70 yr tended to be a significant risk factor (odds ratio, 2.16; 95% CI, 0.58–8.06).


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  		Table 4. Predictors of Core Hypothermia (Tc < 36.0°C) at the Time of Admission to the General Surgical ICU by Multiple Logistic Regression
 
With regard to intraoperative factors, a significant protective factor against core hypothermia was warmer ambient OR temperature (odds ratio, 0.67; 95% CI, 0.51–0.88). Significant risk factors for core hypothermia were use of combined epidural and general anesthesia (odds ratio, 3.39; 95% CI, 1.05–10.88) and duration of surgery longer than 2 h (odds ratio, 4.50; 95% CI, 1.48–13.68). Not using temperature monitoring tended to be a significant risk factor for core hypothermia (odds ratio, 3.00; 95% CI, 0.89–10.12).

Among all the surgical subspecialties, not using temperature monitoring was significantly different (P = 0.006) because the smallest incidence of monitoring was in orthopedic surgery (28.8%) and the largest was in general surgery (57.9%). Almost all of the patients who had surgery performed using an endoscopic technique were admitted with a Tc <36.0°C.

Univariate and multivariate analyses of core hypothermia defined by Tc <35.5°C and Tc <35.0°C were also performed; however, the results (not shown here) were consistent with using a single definition of Tc <36.0°C.

In this study, the number of days in ICU varied from 1–19 days with a mean ± SD of 2.4 ± 3.0 days. The percentages of patients who stayed in ICU 1, 2, and more than 2 days were 59.2% (n = 109), 20.1% (n = 37), and 20.7% (n = 38), respectively. Univariate analysis revealed that only emergency surgery and a total fluid replacement >4000 mL were statistically significant risk factors for longer stay in ICU (P = 0.9272, 0.1786, and 0.1063, respectively).

Because the number of days in the ICU (1, 2, and >2) is an ordinal variable, use of the proportional odds model is reasonable to determine the effect of one clinical variable adjusting for the others. Because of the small number of subjects in the group that stayed for 2 days and more than 2 days, only four predictors were included in this multivariate analysis: emergency surgery, fluid replacement >4000 mL, use of a forced air warming technique, and Tc (Tc <35.0°C). Test of the proportional odds assumption supported the appropriateness of this model (P = 0.2557). The result showed that statistically significant predictors of a longer length of stay in ICU were emergency surgery (odds ratio, 6.30; 95% CI, 2.77–14.31), fluid replacement >4000 mL (odds ratio, 2.54; 95% CI, 1.25–5.18), not using a forced air warming technique (odds ratio, 1.98; 95% CI, 1.05–3.72), and core hypothermia (Tc <35.0°C) tended to be a significant predictor of longer stay in ICU (odds ratio, 1.63; 95% CI, 0.82–3.22).

Eleven patients died in this study, with a total mortality rate of 6.19%. Seven patients (63.6%) were admitted with Tc <36.0°C. Univariate analysis showed that statistically significant risk factors for mortality were high ASA status (P = 0.0098), emergency surgery (odds ratio, 7.83; 95% CI, 2.21–27.74), and a longer stay in ICU (odds ratio, 7.98; 95% CI, 2.21–27.74). Arrival core hypothermia tended to be a significant predictor as well (odds ratio, 2.09; 95% CI, 0.54–8.14 for Tc <36.0°C; odds ratio, 1.77; 95% CI, 0.52–6.01 for Tc <35.5°C; and odds ratio, 2.23; 95% CI, 0.65–7.67 for Tc <35.0°C).


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
This study of a mixed population admitted to the general surgical ICU showed that the incidence of core hypothermia on ICU arrival was 57.1%, 41.3%, and 28.3% when core hypothermia was defined as Tc <36.0°C, Tc <35.5°C, and Tc <35.0°C, respectively. The incidence in the group with a Tc <36.0°C is close to the study of Slotman et al. (1) (51%, Tc <97°F) who studied a mixed population of patients undergoing noncardiac surgery admitted to the general ICU. The incidence defined by Tc <35.0°C is slightly less than that in the study of Frank et al. (20) (33.7%, Tc <35.0°C) and Bush et al. (2) (33.0%, Tc <34.5°C) with patients undergoing vascular surgery. When this incidence is compared with a report from Berry et al. (3) in a general surgical ICU (25.8%, Tc <35.5°C, and 15.8%, Tc <35.0°C), this incidence is increased.

Among all the preoperative factors, heavier body weight was found to be a significant protective factor (adjusted odds ratio, 0.94) against core hypothermia. Because height was not recorded in most of the patients undergoing emergency surgery, body mass index, which would have been more useful, was not included in this study. Warmer preoperative body temperature was another significant protective factor with the adjusted odds ratio of 0.31. This result strongly supports efforts (12) to increase body temperature before surgery that might prevent core hypothermia during operation. In this study, the preoperative body temperatures varied widely from 34.5°C to 39.3°C and had a symmetrical non-normal distribution (P = 0.0184; Kolmogorov-Smirnov test) compared with the study of Mitchell and Kennedy (27) where preoperative body temperature showed a skewed distribution ranging from 35.7°C to 37.8°C. Preoperative body temperature should be recorded and used as a treatable factor to prevent core hypothermia in the perioperative period. The higher the ASA physical status, the greater the risk for core hypothermia (adjusted odds ratio, 3.33 for ASA II and 6.80 for ASA >II). Previous studies have shown that older patients had an increased risk of core hypothermia (1,2,17). However, this study showed that after adjusting for ASA physical status and other variables, age older than 70 years tended to be a significant risk, even though this did not reach statistical significance.

In this study, we found that the extent of a surgical procedure was also a significant risk factor for core hypothermia on ICU arrival. Even though this result is not different from the previous reports, it did remind us that despite new technology and efforts in warming, great care and planning to prevent heat loss is required when major and extensive surgical procedures are performed. Optimal warm ambient OR temperature could be a simple means of preventing heat loss. In our study, warmer ambient OR temperature was a significant protective factor against core hypothermia (adjusted odds ratio, 0.67). This result is in agreement with a previous study (28) that showed that increasing the OR temperature from 20°C to 26°C could prevent core hypothermia during surgery. However, when the OR is too warm, it is not a comfortable working environment and may increase the risk of infection (29). The optimal OR temperature and the patient’s Tc should be considered so that an acceptable working environment is achieved.

The technique of combined epidural and general anesthesia has been introduced into current practice to help decrease the stress response during surgery, decrease intraoperative anesthetic requirement, and produce early awakening and better pain control in the postoperative period (18). We found that this intervention added significant intraoperative risks for core hypothermia with an adjusted odds ratio of 3.39 compared with previous reports showing a frequent incidence of hypothermia with general anesthesia (9). A combined anesthetic technique can cause a depression of both central and peripheral control of body temperature (17), leaving the patient more poikilothermic to ambient temperature with fewer defense mechanisms and a larger decrease in Tc. However, when this technique is chosen, attention should be paid to the prevention of core hypothermia in addition to the level of sympathetic block. Our results warrant further study concerning the outcome of core hypothermia in the presence of combined epidural anesthesia.

In this study, surgery lasting longer than two hours increased the risk (adjusted odds ratio, 4.50) of core hypothermia, although the duration of surgery we reported was shorter than that in previous reports (1,2). In this study, it is of interest that not using temperature monitoring tended to increase the risk of core hypothermia (adjusted odds ratio, 2.62; 95% CI, 0.87–7.85). This result is in agreement with the study of Arkilic et al. (30) that reported a decreased incidence of temperature monitoring during neuraxial anesthesia and strongly supported the guideline about the use of body temperature monitoring in anesthetized patients in whom changes in body temperature are intended, anticipated, or suspected (31).

With the introduction of endoscopic surgery and the use of either irrigation fluid or insufflated gas to facilitate the technique, more perioperative core hypothermia has been reported (5,10,11). Efforts have been made to prevent this hypothermia, but the desired outcome is still questionable (19,30). In this study, almost all of the patients who had surgery performed by an endoscopic technique were admitted with Tc <36.0°C despite great care and aggressive warming during the procedure. The question was raised about what would be the essential significant predictive factor of core hypothermia in this group of patients.

As a result of current economic pressure, the high cost of ICU stay, and the fact that 60% of the patients in this study were in the ICU for one day, it was of interest to find any possible clinical predictors for ICU stay of two days or more. Acute Physiology and Chronic Health Evaluation score was not included as a predictor because the objective of this study was to explore only preadmission clinical factors. A Tc <35°C tended to be a significant predictor (adjusted odds ratio, 1.63; 95% CI, 0.82–3.22) of an increased length of ICU stay. However, not using a forced air warming technique added almost twice the risk (adjusted odds ratio, 1.98) for a longer ICU stay in addition to emergency surgery and IV replacement >4000 mL. In this study, not using a forced air warming system may imply inadequate warming, which is an intervention that can be modified to decrease the length of ICU stay.

The overall mortality in this study was 6.9%, which was slightly more than a previous study (2). In this study, 63.6% of the patients who died were admitted with Tc <36.0°C. Statistically significant preadmission clinical predictors of death were high ASA physical status, emergency surgery, and a longer ICU stay. Although core hypothermia on arrival tended to be a significant predictor, the sample size may not have been large enough to prove this.

In conclusion, the incidence of ICU arrival core hypothermia among patients is still frequent. Also, a high ASA physical status, extent of surgical procedure, the technique of combined epidural and general anesthesia, duration of surgery longer than two hours, and not using temperature monitoring tended to be risk factors. Heavier body weight, warmer preoperative body temperature, and warmer ambient OR temperature were significant protective factors. We conclude that more care should be taken to prevent core hypothermia in this group of patients, including the use of body temperature monitoring.


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  		Table 5. Analysis of Proportional Odds Model for Length of ICU Stay (1, 2, >2 days)
 

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  		Table 6. Predictors of Mortality by Univariable Analysis
 

   Acknowledgments
 
Supported, in part, by the Siriraj Grant for Research Development and Medical Education (SRDM).

The authors wish to thank Professor Thara Tri-takarn for support and input in this study, Dr Patiparn Tumtong who encouraged our study, and Dr Jane Hardy for her help with the manuscript.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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Accepted for publication November 7, 2002.




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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