{"id":9217,"date":"2024-10-15T06:14:44","date_gmt":"2024-10-15T06:14:44","guid":{"rendered":"https:\/\/www.kauveryhospital.com\/ima-journal\/?p=9217"},"modified":"2025-04-09T10:22:31","modified_gmt":"2025-04-09T10:22:31","slug":"thermoregulation-perioperative-hypothermia","status":"publish","type":"post","link":"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-october-2024\/thermoregulation-perioperative-hypothermia\/","title":{"rendered":"THERMOREGULATION & PERIOPERATIVE HYPOTHERMIA"},"content":{"rendered":"

[vc_row][vc_column][vc_column_text]\u25b8BODY TEMPERATURE<\/p>\n

Heat production (THERMOGENESIS)<\/p>\n

Heat loss (THERMOLYSIS)<\/p>\n

\u25b8HEAT \u00a0– product of metabolism\u00a0 \u00a0]<\/p>\n

lost in the environment\u00a0 \u00a0 ]\u00a0 —>\u00a0 \u00a0Temperature Maintained<\/p>\n

\u25b8Normal CORE BODY TEMPERATURE IS 36. 5\u00b0C -37.3\u00b0 C<\/p>\n

Peripheral temperature is typically 2\u00b0c -4\u00b0c lower than core temperature<\/p>\n

DEFINITIONS : <\/b><\/strong><\/h2>\n

Thermoregulation<\/b><\/strong>: Haemostatic process that aims to maintain a constant core temperature.<\/p>\n

Hypothermia<\/b><\/strong>: \u00a0An abnormally low core body temperature, below the physiological normal limit.<\/p>\n

Mild – > 32\u00b0c to 35 \u00b0c<\/p>\n

moderate – 28\u00b0c to 32\u00b0c<\/p>\n

severe – <28\u00b0c<\/p>\n

Hyperthermia<\/b><\/strong>\u00a0: An elevated core body temperature, above the physiological normal limit.<\/p>\n

Inter threshold range:<\/b><\/strong>\u00a0\u00a0The range of core temperature over which no autonomic thermoregulatory responses occur.<\/p>\n

Approximately 37\u00b0c + \/-0.2 c in non-anaesthetised state.<\/p>\n

Balance between heat production \/ Loss \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/b><\/strong><\/h2>\n

Heat production<\/b><\/strong><\/p>\n

Main sources of heat production are<\/p>\n

    \n
  • Basal metabolic process( under endocrine \u00a0control )<\/li>\n
  • Sympathetic activity, vascular tone<\/li>\n
  • Muscular activity<\/li>\n
  • Hormonal activity<\/li>\n<\/ul>\n

    Heat Loss<\/b><\/strong><\/p>\n

    Important mechanisms of Heat loss<\/p>\n

      \n
    • Radiation<\/li>\n
    • Conduction<\/li>\n
    • Convection<\/li>\n
    • Evaporation<\/li>\n<\/ul>\n

      \"\"<\/p>\n

      \"\"<\/p>\n

      PATHWAY OF THERMOREGULATION <\/b><\/strong><\/h2>\n

      Cold receptors \u2013 A alpha fibres \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Heat loss \u2013 Sweating\u00a0Vasodilation<\/p>\n

      Warm receptors \u2013 C fibres \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Heat conservation \u2013 Shivering\u00a0Vasoconstriction<\/p>\n

      Behavioural responses:<\/strong> Dressing appropriately\u00a0Modifying environmental temperature\u00a0Assumption of body positions which oppose skin surface, Increasing voluntary movements to generate heat.<\/p>\n

      NON-SHIVERING THERMOGENESIS\/CHEMICAL THERMOGENESIS <\/b><\/strong><\/h2>\n
        \n
      • Increase in rate of metabolism in Brown Adipose Tissue<\/li>\n
      • Stimulated by Sympathetic system or Catecholamine.<\/li>\n
      • Brown Adipose tissue \u2013 Interscapular space, around great vessels<\/li>\n
      • Brown fat has lot of Mitochondria (rich in ATP) & Sympathetic innervation.<\/li>\n
      • Can produce heat as much as 200%<\/li>\n
      • Lipolysis & Heat generation is mediated \u2013 Beta adrenergic receptors.<\/li>\n
      • Adults rarely have brown fat.<\/li>\n<\/ul>\n

        SHIVERING<\/b><\/strong><\/h2>\n
          \n
        • Increases body heat production in response to decreased core body temperature<\/li>\n
        • Skeletal Muscle activity is a major source of heat.<\/li>\n
        • Shivering arises from posterior hypothalamus<\/li>\n
        • However, shivering is inefficient & induces significant metabolic demand.<\/li>\n<\/ul>\n

          Cutaneous blood flow <\/b><\/strong><\/h2>\n

          \u25b8Major determinant of heat loss<\/p>\n

          \u25b8It is regulated by sympathetic nervous system<\/p>\n

          \u25b8In adult blood flow is 400ml\/min, decreased to 50ml\/min cold, 2800ml\/min in heat<\/p>\n

          \u25b8Subcutaneous venous plexuses hold large volume of blood- fingers, palms ,toes and earlobes -arteriovenous anastomosis \u2013 causes significant heat loss during circulation.<\/p>\n

          Acute haemorrhage —– \u00a0\u00a0\u00a0sympathetic nervous system vasoconstriction —- transfer large blood from venous plexus to central circulation —– \u00a0important blood reservoir<\/p>\n

          Acute Haemorrhage less tolerated in warm environment<\/p>\n

          Hypothalamic Vasodilator response overrides vasoconstrictor response to Hypovolemia<\/p>\n

          Thermoregulation during general anaesthesia <\/b><\/strong><\/h2>\n

          \u25b8\u00a0Body temperature is determined by \u00a0cold environment -poikilothermic<\/p>\n

            \n
          1. Resetting Hypothalamic thermostat<\/li>\n
          2. Reduced temperature (outside)<\/li>\n
          3. Administration of cold iv fluids<\/li>\n
          4. Decreased basal metabolic rate<\/li>\n
          5. Drug induced vasodilation<\/li>\n
          6. Core compartment exposed to room temperature<\/li>\n
          7. Heat required to humidify dry gases<\/li>\n<\/ol>\n

            Under GA, behavioural response is not relevant as patient are unconscious.<\/p>\n

            Thus, thermoregulatory responses under anaesthesia include\u00a0Autonomic response & \u00a0External thermal management<\/p>\n

            Therefore under GA, alterations in autonomic threshold include:-<\/strong><\/p>\n

              \n
            • Increase in warm response threshold<\/li>\n
            • Decrease in cold response threshold<\/li>\n
            • Increase in interthreshold range 2-4\u00b0c<\/li>\n
            • Impaired shivering response due to muscle paralysis<\/li>\n<\/ul>\n

              \"\"<\/p>\n

              Non shivering thermogenesis not significant in adult<\/p>\n

              Thermoregulation under regional anaesthesia <\/b><\/strong><\/h2>\n

              Behavioural response is impaired<\/p>\n

              Inhibition of autonomic thermoregulatory responses, core temperature decreases, skin temperature increases due to vasodilation. Therefore, patient doesn\u2019t feel cold in spite of having a reduced core temperature<\/p>\n

              Also, RA blocks all thermal input from anaesthetized regions. Inhibit tonic cold signals from legs to thermoregulatory center<\/p>\n

              The hypothalamus wrongly interprets this as warming of legs<\/p>\n

              Decreases threshold to trigger vasoconstriction and shivering by 0.6 \u00b0c<\/p>\n

              Peripheral vasoconstriction and shivering is inhibited in blocked areas.<\/p>\n

              Reduction in threshold is proportional to the number of spinal segments blocked<\/p>\n

              Thermoregulation in combined G. A & R. A<\/b><\/strong><\/h2>\n

              Core temperature doesn\u2019t plateau<\/p>\n

              Thus, it continuous to decrease throughout surgery.<\/p>\n

              Phases of hypothermia under general anaesthesia <\/b><\/strong><\/h2>\n

              Phase 1: Redistribution phase <\/b><\/strong><\/p>\n

                \n
              • Occurs during the first hour of G. A<\/li>\n
              • Causes the largest drop in core temperature (0.5- 1.5\u00b0c). Peripheral temperature increases from 33\u00b0c to 35\u00b0c<\/li>\n
              • Redistribution is caused by vasodilation induced by G. A. Redistribution of heat from core to periphery.<\/li>\n<\/ul>\n

                Phase 2: Linear phase <\/b><\/strong><\/p>\n

                  \n
                • Occurs for next 2-4 hrs after G. A<\/li>\n
                • Linear reduction in core temperature. Mainly due to heat loss exceeds heat production.<\/li>\n
                • Heat loss occurs by radiation >convection> evaporation > conduction<\/li>\n<\/ul>\n

                  Phase 3: Plateau phase <\/b><\/strong><\/p>\n

                    \n
                  • Occurs after 3-4 hrs of G. A<\/li>\n
                  • Core temperature stops reducing and stabilizes. Heat loss = heat production<\/li>\n<\/ul>\n

                    Reduces heat loss from body. This phase absent in perpheral \/ autonomic neuropathy.<\/p>\n

                    \"\"<\/p>\n

                    Phases of hypothermia during Regional anaesthesia <\/b><\/strong><\/h2>\n

                    Phase 1: Redistribution phase <\/b><\/strong><\/p>\n

                      \n
                    • Core temperature reduces first one hour due to vasodilation.<\/li>\n
                    • Peripheral temperature increases due to redistribution<\/li>\n
                    • Large drop in core temperature during R. A<\/li>\n<\/ul>\n

                      Phase 2: Linear phase <\/b><\/strong><\/p>\n

                        \n
                      • Occurs during next 2- 4 hrs after R. A<\/li>\n
                      • Mainly due to heat loss exceeding heat production<\/li>\n<\/ul>\n

                        Phase 3: Plateau phase <\/b><\/strong><\/p>\n

                          \n
                        • Absent in R. A. This is because RA blocks nerve supply to blood vessels in the legs.<\/li>\n
                        • These prevents any thermoregulatory vasoconstriction.<\/li>\n<\/ul>\n

                          Thermoregulation in Newborns <\/b><\/strong><\/h2>\n
                            \n
                          • No shivering or effective vasoconstriction occurs.<\/li>\n
                          • Having a large surface area to weight ratio which increases heat loss.<\/li>\n
                          • Lesser subcutaneous fat for insulation.<\/li>\n
                          • Non-shivering thermogenesis is however very effective.<\/li>\n
                          • No thermoregulatory sweating occurs in newborns.<\/li>\n
                          • No sweating ability<\/li>\n
                          • Higher metabolic rate compared to adults (per kg)<\/li>\n
                          • Brown fat & non shivering thermogenesis is more important in neonates.<\/li>\n<\/ul>\n

                            Sites of temperature monitoring <\/b><\/strong><\/h2>\n

                            \"\"<\/p>\n

                            Effects of hypothermia <\/b><\/strong><\/h2>\n

                            Thermoregulatory response: cutaneous vasoconstriction Shivering<\/p>\n

                            Non shivering thermogenesis (infants)<\/p>\n

                            Behavioural changes<\/p>\n

                            Pathological responses<\/p>\n

                            CVS: Heart rate decreases – slowing of discharge from SA node<\/p>\n

                              \n
                            • Paradoxical vasodilation<\/li>\n
                            • Hypotension, Dysrhythmias, MI<\/li>\n
                            • Cardiac output & venous capacitance<\/li>\n
                            • Increase peripheral and pulmonary vascular resistance<\/li>\n<\/ul>\n

                              CNS: <34 \u00b0c —mental confusion<\/p>\n

                                \n
                              • <32\u00b0c —– loss of consciousness<\/li>\n
                              • Decreases CMRO2<\/li>\n
                              • Protects against cerebral ischemia<\/li>\n
                              • Delayed awakening<\/li>\n<\/ul>\n

                                Haematology: \u00a0Coagulopathy<\/p>\n

                                Local effect: Impaired wound healing<\/p>\n

                                  \n
                                • Drug \u00a0metabolism<\/li>\n
                                • Decreases reliability of pulse oximetry, Ecg, IBP<\/li>\n<\/ul>\n

                                  Oxygenation: Shift of oxyhemoglobin curve to left<\/p>\n

                                    \n
                                  • Increase O2 consumption and co2 production<\/li>\n
                                  • Increase tissue hypoxia and metabolic acidosis<\/li>\n<\/ul>\n

                                    Effect of Hyperthermia <\/b><\/strong><\/h2>\n

                                    Thermoregulatory response: cutaneous vasodilation, sweating & behavioural changes<\/p>\n

                                    Pathological Responses<\/p>\n

                                    Cvs :\u00a0 Inc. HR, inc cardiac output<\/p>\n

                                      \n
                                    • \n
                                        \n
                                      • \n
                                          \n
                                        1. P remain stable due to vasodilation<\/li>\n<\/ol>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

                                          Cns : \u00a0Irritability — heat stroke,<\/p>\n

                                          >42\u00b0c — loss of consciousness<\/p>\n

                                          Musculo skeletal: Fluid & electrolyte loss —– muscle cramps<\/p>\n

                                          Beneficial effect of perioperative hypothermia <\/b><\/strong><\/h2>\n
                                            \n
                                          • Hypothermia reduces the metabolic demand<\/li>\n
                                          • O2 consumption\u00a0 5% _ 7% for every Degree Celsius<\/li>\n
                                          • 1-3\u201dC decrease protects against cerebral ischemia and arterial hypoxemia<\/li>\n
                                          • Mild Hypothermia (33-36)- Beneficial: cardiac surgeries, aneurysmal clipping, cardiac arrest, stroke, traumatic brain injury acute MI, birth injury<\/li>\n
                                          • Surface cooling causes hypothermia – shivering which delays core cooling<\/li>\n<\/ul>\n

                                            Risk factors <\/b><\/strong><\/h2>\n
                                              \n
                                            • Young age<\/li>\n
                                            • Low core temperature preoperatively<\/li>\n
                                            • Male sex<\/li>\n
                                            • General > Regional anaesthesia<\/li>\n<\/ul>\n

                                              Prevention<\/b><\/strong>\u00a0<\/b><\/strong>of hypothermia in Adults <\/b><\/strong><\/h2>\n
                                                \n
                                              • Maintain OT temperature between 21_23\u00b0c<\/li>\n
                                              • Maintain intraoperative normothermia<\/li>\n
                                              • Adequate pre-warming for 30 mins prior to regional anaesthesia<\/li>\n
                                              • Correct underlying problems —- Sepsis<\/li>\n
                                              • IV fluids and blood at 4\u00b0c reduces core temperature by 0.25 \u00b0 c. So warmed iv fluids and blood products useful.<\/li>\n<\/ul>\n

                                                Prevention of hypothermia in Neonates <\/b><\/strong><\/h2>\n

                                                Maintain neutral thermal environment<\/p>\n

                                                Skin surface warming:<\/p>\n

                                                  \n
                                                • Hot water warmers<\/li>\n
                                                • Infrared radiant heaters<\/li>\n
                                                • Convection heaters<\/li>\n
                                                • Use plastic wrap\/ covers \/ hats \/ head caps<\/li>\n<\/ul>\n

                                                  Prevent heat losses:<\/p>\n

                                                    \n
                                                  • Transport newborn in incubator and not bed with overhead heaters.<\/li>\n
                                                  • Increases OT temperature to maximum levels (around 26\u00b0c if tolerable)<\/li>\n
                                                  • Air humidification<\/li>\n
                                                  • Place forced air warming blanket to reduce conductive heat loss<\/li>\n
                                                  • Use of warm iv fluids \u2013 place fluid warmer close to iv access site.<\/li>\n<\/ul>\n

                                                    TREATMENT<\/b><\/strong>\u00a0<\/b><\/strong><\/h2>\n
                                                      \n
                                                    • Supplemental Oxygen<\/li>\n<\/ul>\n

                                                      \"\"<\/p>\n

                                                      \"\"Dr. Velmurugan Deisingh<\/strong>
                                                      \nHead of Department of Anaesthesia
                                                      \nKauvery Hospital, Chennai<\/p>\n

                                                       <\/p>\n

                                                       <\/p>\n

                                                      \"\"Dr. Varalakshmy<\/strong>
                                                      \n2nd<\/sup> DNB Resident – Anaesthesia
                                                      \nKauvery Hospital, Chennai[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"

                                                      [vc_row][vc_column][vc_column_text]\u25b8BODY TEMPERATURE Heat production (THERMOGENESIS) Heat loss (THERMOLYSIS) \u25b8HEAT \u00a0– product of metabolism\u00a0 \u00a0] lost in the environment\u00a0 \u00a0 ]\u00a0 —>\u00a0 \u00a0Temperature Maintained \u25b8Normal CORE BODY TEMPERATURE IS 36. 5\u00b0C<\/p>\n","protected":false},"author":2,"featured_media":9218,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[80],"tags":[],"class_list":["post-9217","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ima-journal-october-2024"],"yoast_head":"\nTHERMOREGULATION & PERIOPERATIVE HYPOTHERMIA<\/title>\n<meta name=\"description\" content=\"Thermoregulation: Haemostatic process that aims to maintain a constant core temperature. 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