C8INTRAOPERATIVE PHASE: FLUID WARMING

StudyParticipantsInterventions
Camus 1996
Trial held in France
Funding: not stated
Inclusion & exclusion criteria: major abdominal surgery lasting at least 3 hours; none of the patients were obese, febrile or had a history of endocrine disease.
Surgery type: elective; surgical speciality: abdominal; surgery duration: 1 to 3 h
Anaesthesia type: general; anaesthesia duration more than 1h; premed: hydroxyzine 100 mg orally 1 h prior to surgery; no. Of intubated/ventilated patients postoperatively: not stated -
ASA grade: I–II; age (range): 45; gender (m/f): 9:9; BMI: not stated
comorbidities: not stated; inspired gases not warmed;IV fluids infused at a rate of 8–10 ml/kg/h through an 18g cannula; all patients warmed with electric blanket in PACU until temperature reached preinduction values; intubation of trachea pancuronium(0.1mg/kg); most patients in lithotomy position;
  1. fluid tube-warming (Hotline; Level 1) + electric blanket (40°C) (electroconcept) (active pt + active fl); duration:; 37°C; n=9
  2. room temp IV fluids + electric blanket (Electroconcept) (40°C ) (active pt + active fl); duration:; amount; n=9
Cooper 1994
Trial held in Australia
Funding: not stated
Inclusion & exclusion criteria: routine hysteroscopic surgery for menorrhagia;
Surgery type: not stated; surgical speciality: gynaecology; surgery duration: not stated
Anaesthesia type: not stated/unclear; anaesthesia duration not stated; premed: majority received danazol 200 mg 3 times daily for 6 weeks as an endometrial preperatory agent; stated -
ASA grade: not stated; age (range): 40 years(31–49); gender (m/f): 0:14; BMI: not stated
comorbidities: not stated; uterine cavity length: 6v9cm; 9 pts:total transcervical resection of the endometrium, of whom 3 had simultaneous hysteroscopic polypectomy; 4 patients underwent rollerball ablation of the endometrium; 1 patient had extensive myoma resected;
  1. Sterile 1.5% glycine (Althin ift 220, Althin Medical ab) (active fl); duration:; 37.5°C; n=not stated
  2. Usual care; duration:; 20 °C; n=not stated
Dyer 1986
Trial held in Australia
Funding: not stated
Inclusion & exclusion criteria: transurethral resection of prostate under spinal anaesthesia
Surgery type: not stated; surgical speciality: urology; surgery duration: over 3 h
Anaesthesia type: regional; anaesthesia duration not stated; premed: not stated;
ASA grade: not stated; age (range): 69 years; gender (m/f): 100:0; BMI: not stated
comorbidities: not stated; theatre temp:20.7–21.3°C; resection time: w:29.2min(SD15.7)vs c:32.4(SD15.4);
  1. 1.5% glycine warmed (Contherm 150 incubator set (passive fl); duration: not stated; 37°C (temperature fell rapidly; mean: 33°C); n=22
  2. Usual care; n=25
  3. Reflective blanket
  4. Reflective blanket + warmed irrigation fluid
Ellis-Stoll 1996
Trial held in USA
Funding: not stated
Inclusion & exclusion criteria: women scheduled for laparoscopic cholecystectomy
Surgery type: not stated; surgical speciality: abdominal; surgery duration: mixed
Anaesthesia type: not stated/unclear; anaesthesia duration not stated; premed: not stated;
ASA grade: not stated; age (range): 43 years(26 to 64); gender (m/f): 0:50; BMI: not stated
comorbidities: not stated; study did not state how many patients randomised to each group- assuming equal randomisation;all patients upper chest and arms covered with prewarmed blanket; none of the prewarmed IV fluid bag's initial temperature exceed 44°C
  1. Actively warmed IV fluids (active fl); duration:; 37°C; n=25
  2. Room temperature IV fluids; duration:; temperature dropped to rt during surgery; n=25
Hasankhani 2005
Trial held in Iran
Funding: not stated
Inclusion & exclusion criteria: Excl: age: <18 or >55 yearspreoperative use of calcium channel blockers, preoperative sublingual temp >38.°C or <35.5°C; history of endocrine disease, obesity, pregnancy, or anaemia.
Surgery type: elective; surgical speciality: orthopaedics; surgery duration: 1 to 3 h; ASA: I
Anaesthesia type: general; anaesthesia duration more than 1h; premed: atropine (0.2–0.4mg); no. Of intubated/ventilated patients postoperatively: not stated -
ASA grade: I–II; age (range): 36 years(18–55); gender (m/f): 39:21; BMI: not stated
comorbidities: not stated; during surgery all pts covered by cotton blankets & surgical drapes & covered w/cotton blanket before transport to PACU;or temp:24°C; inspired gases not warmed.;p.9-set patient temp of fluid warmer to warming IV fluids: 39.5°C at 800cc/h;
  1. Warmed IV fluids via a dry fluid warmer (Biegler) (active fl); duration: not stated; tbag:24;tprox:36–38°C; distal:32–38°C; n=30
  2. Room temp IV fluids usual care; duration: not stated; 24.4°C n=30
Heathcote 1986
Trial held in Australia
Funding: not stated
Inclusion & exclusion criteria:
Surgery type: not stated; surgical speciality: not stated; surgery duration: not stated
Anaesthesia type: regional; anaesthesia duration: not stated; premedication:;
ASA grade: not stated; age (range):; gender (m/f):; BMI: comorbidities: not stated;
  1. 1.5% glycine warmed (Contherm 150 incubator) set (passive fl); duration:; 37°C(mean 33°C); n=19
  2. Usual care; duration:; amount; n=21
Jaffe 2001
Trial held in USA
Funding: not stated
Inclusion & exclusion criteria: incl and excl criteria not stated
Surgery type: not stated; surgical speciality: urology; surgery duration: 30 to 60 min
Anaesthesia type: not stated/unclear; anaesthesia duration not stated; premed: not stated;
ASA grade: not stated; age (range): 71.2 years (52–89); gender (m/f): 56:0; BMI: not stated
comorbidities: not stated;
Patients from both groups were coverd with a gown and warmed blanket (45°C from neck to level of umbilicus); at end of procedure patients were covered with a new warm blanket; in PACU all patients had continuous bladder irrigation with room temperature irrigation fluid; Room temperature:21°C.
  1. Warmed irrigation fluid (33°C); unclear actively or passively warmed (active fl); duration: not stated; 33°C; n=29
  2. Room temp irrig fluid usual care; duration:; 21°C; n=27
Kelly 2000
Trial held in Phillipines/Cuba/USA
Funding: not stated
Inclusion & exclusion criteria: i: Patients undergoing knee arthroscopy; e:<18 or >65 years; presence of co-existing disease affecting patients ability to maintain normal core temp (i.e. Thyroid disease);contraindication or unwillingess to undergo spinal anaesthesia;
Surgery type: not stated; surgical speciality: orthopaedics; surgery duration: mixed
Anaesthesia type: regional; anaesthesia duration not stated; premed: midazolam (IV) administered to all patients just before departing the preoperative holding area; no.
ASA grade: I–II; age (range): 36(20–56); gender (m/f): not stated; BMI: not stated
comorbidities: not stated;
Mean duration of surgery:44min (18–92);all IV fluids administered at room temperature; if external warming devices were required during surgery or recovery, patient withdrawn from study; all patients were covered with single cloth sheet before application of sterile drape
  1. Prewarmed saline irrigation solution in a warming cabinet (passive fl); 40°C n= 12
  2. Usual care; n=12
Kurz 1995
Trial held in USA
Funding: Supported by NIH grant
Inclusion & exclusion criteria: patients undergoing colon surgery. None of the patients had a history of thyroid disease, dysautonomia, Raynaud’s syndrome or malignant hyperthermia. Surgery type: elective; surgery duration: 1 to 3 h; Anaesthesia type: general; anaesthesia duration: not stated; premed: Oral diazepam (10 mg); no; ASA grade: I–III; age (range): 57 years (SD 15): 59 (SD 14); BMI: not stated
comorbidities: not stated
  1. Forced air cover (Augustine Medical) + warmed IV fluids (fluid warmer)-activated (active warming device); duration:; 40°C; n=39
  2. Forced air cover (Augustine Medical) + warmed IV fluids (fluid warmer)- not activated (active + passive); duration:; 'ambient temp'; n=35
Monga 1996
Trial held in USA
Funding: not stated
Inclusion & exclusion criteria: Patients undergoing TURP for treatment of bladder outlet obstruction secondary to benign prostatic hypertrophy
Surgery type: elective; surgical speciality: urology; surgery duration: not stated
Anaesthesia type: general and regional; anaesthesia duration not stated; premed: not stated;
ASA grade: not stated; age (range): 69.2 years; gender (m/f): 28:0; BMI: not stated
comorbidities: not stated; study did not indicate how many patients randomised to each group. Assumed equal numbers randomised to the warmed (active and passive) and control group.
  1. Warmed irrigation fluid (Abbott level-one fluid warmer) (active fl); duration:; amount; n=not stated
  2. Unwarmed fluid (room temperature irrigation fluid); duration:; 17°C n=not stated
  3. Passively warmed fluids; 35°C n=not stated
Moore 1996
Trial held in USA
Funding: not stated
Inclusion & exclusion criteria: incl: women undergoing elective operative laparoscopic procedures ranging from diagnostioc laparascopy to extensive lysis of adhesions& removal of adnexal structures; excl: Patients weighing less than 40 or greater than 100 kg, pregnant or undergoing
Surgery type: elective; surgical speciality: gynaecology; surgery duration: 1 to 3 h
Anaesthesia type: general; anaesthesia duration more than 1h; premed: midazolam (1–2 mg) IV & lidocaine 40 mg IV; ASA grade: not stated; age (range): 32; gender (m/f): 0:35; BMI: 26 kg/m2
comorbidities: not stated;
Room temp: 20°C; In 6 patients surgery time was significantly shorter and did not require irrigation fluid; if patient’s oesophageal temperature dropped below 34°C, patient was rewarmed by increasing the temp setting of heating blanket & using warmed blankets & warmed IV fluids
  1. Lactated Ringer’s solution through a pressurized fluid warming system (level 1) (active fl); 39°C; n= 13
  2. Ambient temp lactated ringer’s solution usual care; 20–22°C; n=16Patients in both groups laid on a heating blanket (37.8°C) before induction until throught the procedure; Patients were covered with blankets before induction of anaesthesia on upper extremities.
Motamed 1998
Trial held in Canada
Funding: not stated
Inclusion & exclusion criteria: incl: patients diagnosed w/benign or malignant tumor of colon; colonic resection. None of the patients suffered from inflammatory bowel, malnutrition, recent significant weight loss, anaemia, morbid obesity, endocrine disorders or pyrexia.
Surgery type: not stated; surgical speciality: urology; surgery duration: 1 to 3 h
Anaesthesia type: general and regional; anaesthesia duration not stated; premed: none administered; ASA grade: I–II; age (range): 62 years; gender (m/f): 15:15; BMI: not stated
comorbidities: not stated;
Humidity: between 35–42%; stated OR and recovery room temperature measured and similar for both groups; in the unwarmed group, temperature was allowed to decrease during surgery & recovery and no rescue measure instituted if core temp<33.5 °C; no patients had core temp<33.5 °C;
  1. convective warm air blanket (Mallinckrodt) + IV fluids (active pt + active pt); duration: from induction, during and after surgery; blanket: 42°C; blood warmer: 37°C; n=15
  2. usual care usual care; n=15
Muth 1996
Trial held in Germany
Funding: not stated
Inclusion & exclusion criteria: i:ASA III of either sex undergoing abdominal aortic aneurysm;
Surgery type: elective; surgical speciality: abdominal; surgery duration: 1 to 3 h
Anaesthesia type: general; anaesthesia duration more than 1h; premed: flunitrazepam(1–2 mg p.o); ASA grade: III+; age (range): 64.5 years; gender (m/f): not stated; BMI: not stated
comorbidities: not stated;
Fresh gas flow:4 l/min; all blood products prewarmed in a water bath(unitherm) at 37°C prior to transfusion; no othe r warming devices-blankets, forced-air blowers or inspired gas heaters were used for either group.
  1. IV fluids and blood products (Hotline Level 1) (active fl); duration:; 37°C n=25
  2. IV fluids + prewarmed blood products usual care; duration:; amount; n=25
Patel 1996
Trial held in USA
Funding: loan of Hotline by Level 1 Technologies
Inclusion & exclusion criteria: incl: elective ASA I–III orthopaedic or gynaecologic surgery >2 hrs; excl: emergency surg, calcium channel blocker therapy, preoperative hypothermia (<35.5°C), hyperthermia (temp >38°C), head injury, otitis, presence of nasogastric tube
Surgery type: elective; surgical speciality: mixed; surgery duration: over 3 h
Anaesthesia type: general; anaesthesia duration not stated; premed: not stated; -
ASA grade: mixed; age (range): 41; gender (m/f): 14:25; BMI: not stated
comorbidities: not stated;
Room temperature: 20–21°C; fresh gas flow: 1 and 4 l/min; ventilation controlled to maintain PET CO2 30 to 35 mm Hg;
  1. Hotline fluid warmer (concurrent water heat exchange, level 1 technologies) (active fl); duration:; 35–36 °C; n= 24
  2. Flotem iie (dry heat exhange technology, datachem inc) (active fl); duration:; 28–38°C; n=25
Patel 1997
Trial held in USA
Funding: loan of Hotline by Level 1 technologies
Inclusion & exclusion criteria: incl: elective ASA I–III orthopaedic(n=19), gynaecological (n=15) & general surgery exceeding 2 hrs; excl: emergency surgery, calcium channel blocker therapy, preoperative temp(<35.5°C or >38°C ), head injury, otitis, presence of nasogastric tube, Surgery type: elective; surgical speciality: mixed; surgery duration: over 3 h
Anaesthesia type: general; anaesthesia duration not stated; premed: not stated;
ASA grade: mixed; age (range): 41; gender (m/f): 14:25; BMI: not stated
comorbidities: not stated;
Room temperature: 20–21°C; fresh gas flow: 1 and 4 l/min; ventilation controlled to maintain PET CO2 30 to 35 mm Hg;

Intra: thermal insl+warmed IV fluids vs FAW
Post: thermal insl vs usual care
  1. Reflective blankets, head covers & leggings (thermadrape)+iv fluids[Hotline fluid warmer (concurrent water heat exchange, Level 1 Technologies)] (active fl); duration: applied in the hold area through op and recovery. Unclear how long before induction
  2. Upper body convective warming (Bair Hugger, Augustine Medical)+ IV fluids (active fl); duration: after induction until end of surgery; cotton sheet; bh:43°C IV:21°C n=19
Pit 1996
Trial held in Netherlands
Funding: not stated
Inclusion & exclusion criteria: incl: patients willing to undergo spinal anaesthesia; Excl criteria not stated.
Surgery type: not stated; surgical speciality: urology; surgery duration: 30 to 60 min
Anaesthesia type: regional; anaesthesia duration not stated; premed: not stated;
ASA grade: not stated; age (range): 72 years (59–86); gender (m/f): 59:0; BMI: not stated
comorbidities: not stated;
Resection time not sig diff; volume of irrig fluid not stated; IV fluid-room temperature during and after TURP; after TURP, continuous flow of irrigation fluid at room temperature.
  1. intermittent irrigation with 5% sorbitol containing chlorhexidine (fluid heater, Level 1) (active fl); duration:; set at 37.5°C; never <36.8°C; n=28
  2. room temperature irrigation fluid usual care; duration:; 20.6°C; n=31
Schmeid 1996
Trial held in Austria
Funding: Augustine Medical; Mallinckrodt donated thermocoup
Inclusion & exclusion criteria: i: pts undergoing initial, unilateral total hip arthroplasty; none of the arthroplasties was for treatment of tumour. E: patients with history of excessive bleeding, bruising, having PTT>35s, PT< 70% clot formation, fibrinogen <200 mg/dl, platelet count < 100,000/μL;
Surgery type: elective; surgical speciality: orthopaedics; surgery duration: 1 to 3 h
Anaesthesia type: general; anaesthesia duration not stated; premed: 10 mg oral diazepam 1–2 hr before surgery; no.
ASA grade: I–III; age (range): 63 years (SD 10): 63 (10); gender (m/f): 23:37; BMI: not stated
comorbidities: not stated;
Room temp: 21°C; blood loss replaced w/colloid, haemodilution blood, scavenged red cells & allogeneic transfusions; intraop colloid(haemodilution): 870 v 880 ml; intraop colloid (additional):217 ml (SD 303) v 80 (SD 173); intraop blood(haemodilution):470 ml vs 450 ml
  1. Forced air warming (upper))+ warmed intravenous fluids (37°C (active pt + active fl); duration:; pts temp maintained near 36.5°C; FAW:high; IV-37°C; n= 30
  2. Not stated usual care; duration:; patients temperature allowed to decrease to 35°C; n=30
Smith 1998
Trial held in USA
Funding: not stated
Inclusion : type of surgery: laparasocpy (74%), hysterectomy(21%), cone biopsy (14%); Exclusion: head injury, otitis, and preoperative temp greater or equal to 38°C or less than or equal to 35.5°C and patients taking calcium channel blockers.
Age: 33 (SEM 2):
Surgery type: elective; surgical speciality: gynaecology;
Duration of surgery: 67 min (SEM 16): 75 (SEM 15)
Anaesthesia type: general; anaesthesia duration more than 1h; premed: not stated;
ASA grade: I–III; age (range): 33; gender (m/f): 0:38; BMI: not stated;
comorbidities: not stated; gas flow: 2l/min; room temp:@ 21°C;
  1. Hotline (Level 1) (active fl); duration: until end of surgery; then rt fluids; set point: 42°C (delivers at 38–39 °C); n=18
  2. Room temperature fluids usual care; 21°C; n=20
Smith 1998b
Trial held in USA
Funding: not stated
Inclusion & exclusion criteria: Inclusion: type of surgery: major gynaecologic, orthopaedic & general surery scheduled to last at least 90 min; Exclusion: emergency surgery, preoperative use of calcium channel blockers, head injury, otitis, and preoperative sublingual temp ≥ 38°C;
Surgery type: elective; surgical speciality: gynaecology; surgery duration: 30 to 60 min
Anaesthesia type: general; anaesthesia duration more than 1h; premedication: not stated; no. ASA grade: mixed; age (range): 44; gender (m/f): 15:41; BMI: not stated
Comorbidities: not stated; gas flow: 2 l/min; room temp:@ 21°C; sublingual temp measured preoperative and postoperative; cessation of FAW after 131 min and 165 min fo the intervention and control goups, respectively.
  1. Hotline (Level 1) (active fl); duration: until end of surgery; then rt fluids; set point: 42°C (delivers at 38–39 °C); n=31
  2. Room temperature fluids (room temp IV fluids); duration:; 21°C; n=30
Steinbrook 1997
Trial held in USA
Funding: not stated
Inclusion & Exclusion criteria: Patients undergoing major intraabdominal surgery with no contraindication to epidural anaesthesia. Excluded: if ASA status IV or greater, evidence of malnutrition, anaemia, fever or an endocrine disorder.
Surgery type: not stated; surgical speciality: abdominal; surgery duration: not stated
Anaesthesia type: general and regional; anaesthesia duration not stated; premed: IV midazolam (1 to 4 mg) and fentayl (100 to 250 μg);
ASA grade: mixed; age (range): 45; gender (m/f): not stated; BMI: not stated
comorbidities: not stated;
Ambient temp: 20–22°C in OR and PACU; inspired gases not heated or actively humidified but passive humidificantion provided with HME filter for all patients; postoperative analgesia:patient controlled epidural infusion bupivacaine 0.125% with hydromorphone 0.02 mg/ml.
  1. Bair Hugger (Augustine Medical) + IV fluids (Fenwal model) (active pt + active fl); duration: FAW: maintained pt oesophageal temperature clsoe to 37°C; IV fluids: 37°C; n=5
  2. Not stated usual care; duration:; FAW or active IV not used unless patient temp <35°C; n= 4
Zhao 2005
Trial held in China
Funding: not stated
Inclusion & exclusion criteria: inc: Patients scheduled for abdominal surgery lasting at least 2 hours; Ex: pts w/coagulation disorder, severe malnutirition (total plasma albumin <3.0 g/l, white blood count <2.5x109/l), recent history of fever or infection, history of endocrine disease; Patients with recent use of immunosuppresants perioperative phase: intrafluids
Surgery type: not stated; surgical speciality: not stated; surgery duration: not stated
Anaesthesia type: general; anaesthesia duration more than 1h; Premedication; no; ASA grade: I–II; age (range):52(SD 13): 44 (SD 15); 18–70; gender (m/f): 23:17; BMI: not stated
comorbidities: not stated;
Concurrent treatments, ward temperature, irrigation fluid, IV fluid, humidity, air flow
*FAW: lowered to medium 41–42 if core temperature went above 37.8°C.
Colloid infusion: 800 ml (SD 474) v 945 (SD 394);
  1. Forced air warming + actively warmed intravenous solutions including blood (39°C (active pt + active fl); duration:; FAW: high (42–43°C)*fluid: warmflo:39°C; n=20
  2. Single layer of cotton sheet usual care; duration:; amount; n=20

From: APPENDIX C, CHARACTERISTICS OF INCLUDED STUDIES

Cover of The Management of Inadvertent Perioperative Hypothermia in Adults
The Management of Inadvertent Perioperative Hypothermia in Adults [Internet].
NICE Clinical Guidelines, No. 65.
National Collaborating Centre for Nursing and Supportive Care (UK).
Copyright © 2008, National Collaborating Centre for Nursing and Supportive Care.

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