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Year : 2011  |  Volume : 1  |  Issue : 2  |  Page : 73-77

Efficacy of intravenous fluid warming for maintenance of core temperature during lower segment cesarean section under spinal anesthesia

Department of Anesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Web Publication17-Mar-2012

Correspondence Address:
Sandeep Kundra
Department of Anesthesiology, Dayanand Medical College and Hospital, Ludhiana - 141 001, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-4472.93990

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Introduction: Maintenance of body temperature of obstetrical patients undergoing cesarean section is complicated by a variety of factors including heat loss to atmosphere, infusion of fluids at room temperature, disruption of thermoregulatory mechanisms by epidural or spinal anesthesia and redistribution hypothermia. Infusion of warm fluids is an important method of heat conservation. Hence, we evaluated the efficacy of intravenous fluid warming in preventing hypothermia by observing the change in core temperature with intravenous fluids at room temperature (22°C and 39°C) in patients undergoing lower segment cesarean section under spinal anesthesia.
Materials and Methods: Sixty-four patients belonging to ASA grade I and II were randomly allocated to either of the two groups. Group I received intravenous fluids at room temperature (22°C) and group II received intravenous fluids via fluid warmer (39°C). Core temperature was recorded at every 1 min for the first 5 min, followed by 10 min till the end of surgery using a tympanic thermometer.
Results: The mean decrease in core temperature in group I was -2.184 ± 0.413 and -1.934 ± 0.439 in group II. The comparison of group I and II showed a statistically significant difference in mean core temperatures at times 5, 50, 60, 70, 80 and 90 min and immediately on arrival in the recovery room. A lower incidence of shivering was seen in group II patients, but the difference in the two groups was not statistically significant.
Conclusion: Infusion of warm intravenous fluids resulted in a lesser degree of fall in core temperature, thereby providing a significant temperature advantage; however, this did not translate to prevention of postoperative shivering.

Keywords: Hypothermia, intravenous fluid warming, shivering, spinal anesthesia

How to cite this article:
Goyal P, Kundra S, Sharma S, Grewal A, Kaul TK, Singh M R. Efficacy of intravenous fluid warming for maintenance of core temperature during lower segment cesarean section under spinal anesthesia. J Obstet Anaesth Crit Care 2011;1:73-7

How to cite this URL:
Goyal P, Kundra S, Sharma S, Grewal A, Kaul TK, Singh M R. Efficacy of intravenous fluid warming for maintenance of core temperature during lower segment cesarean section under spinal anesthesia. J Obstet Anaesth Crit Care [serial online] 2011 [cited 2022 Jul 2];1:73-7. Available from: https://www.joacc.com/text.asp?2011/1/2/73/93990

  Introduction Top

Hypothermia, defined as core temperature below 36°C, during spinal anesthesia is certainly far more common than generally appreciated. The maintenance of body temperature of obstetrical patients undergoing cesarean section is complicated by a variety of factors, including heat loss to atmosphere due to cool operating room, the infusion of fluids at operating room temperature, disruption of the normally coordinated thermoregulatory mechanisms by epidural/spinal anesthesia and redistribution hypothermia. [1] Neuraxial anesthesia impairs central autonomic thermoregulatory control, [1] possibly by increasing apparent (as opposed to actual) leg skin temperature. [2] Core temperatures 1-2°C below normal have been associated with adverse outcomes, such as shivering, an increased incidence of surgical wound infection, prolonged hospitalization, morbid cardiac events, increased blood loss, allogeneic transfusion requirements, etc. [3],[4] Apart from the distress hypothermia causes to the patients, shivering produces undesirable physiological consequences such as raised oxygen consumption and hypoxemia, increased cardiac work, raised carbon dioxide production, lactic acidosis and lower mixed venous oxygen saturation and decreases the mother-baby bonding in the postoperative period. [5]

Among the many methods to maintain body temperature in the operation theater and recovery room, the administration of warm intravenous fluids (I.V.) seems to be easy and physiological. Patients who receive operating room temperature intravenous fluids had a higher incidence of shivering than patients who were given warm fluids. [5],[6] It has been shown that rapid infusion of warm I.V. fluids may alter the rate of shivering, depending on the temperature of the fluids. [7] Few studies have, however, reported that warming I.V. fluids did not prevent hypothermia in term parturients undergoing elective cesarean section. [8] In view of the conflicting reports by various authors, we evaluated the efficacy of I.V. fluid warming in maintenance of core temperature in patients undergoing lower segment cesarean section (LSCS) under spinal anesthesia.

  Materials and Methods Top

The study was conducted after approval by the Hospital Ethical Committee on 64 obstetrical patients belonging to ASA grade I and II, scheduled for elective LSCS under spinal anesthesia. A written informed consent was taken from all patients prior to inclusion in the study. Patients were randomly divided using computer-generated random numbers into two groups I and II of 32 patients each.

Group I: Patients were infused I.V. fluids at operating room temperature (22°C). (I.V. fluid containers having been kept in the operation theater at least 1 h before start of surgery and also ensuring that the surface temperature of the fluid container was as required.)

Group II: Patients were infused with warm I.V. fluids (39°C) by using a fluid warmer (Astotherm plus AP220, FUTUREMED).

A thorough preanesthetic check up was carried out on all patients as per standard protocols. Patients with preoperative temperature >38°C or <36°C; patients with impacted wax, external/middle ear infection, tympanic membrane perforation, urinary tract infection, diabetic autonomic neuropathy or any neurological disease, emergency surgery; and patients with indwelling epidural catheter for labor analgesia were excluded from the study.

All patients received premedication in the form of tablet Ranitidine 150 mg the night before surgery and 150 mg in the morning of the surgery with a sip of water.

Baseline blood pressure, pulse rate, SpO 2 and core temperature (tympanic membrane) were recorded preoperatively in all patients. The operating room temperature was also recorded at this time. The operation room temperatures remained between 21 and 22 degrees centigrade throughout the surgery, which is a norm in our hospital settings. All patients were preloaded with 0.9% sodium chloride 10 mL/kg transfused within 30 min before establishment of the subarachnoid block. The temperature of the infusing fluid depended on the group of the patient (either 22°C in group I or 39°C in group II).

Subarachnoid block was achieved under strict aseptic precautions in the left lateral position using a 26 G (Quincke's) needle introduced in the L 3 -L 4 intervertebral space. After obtaining a free flow of cerebrospinal fluid, bupivacaine 0.5% (heavy) 2.5 mL was injected in the subarachnoid space. The patient was made supine immediately and surgery commenced after achieving block level of T6. During the intraoperative period, patients were completely covered in surgical drapes. Vital parameters like NIBP, HR and SpO 2 were recorded at every 1 min for the initial 5 min, followed by every 10 min till the end of surgery. All patients received I.V. infusion at temperatures depending on the group allocation, at the rate of 10 mL/kg/h of crystalloid solution.

Core temperature (tympanic membrane) was recorded at every 1 min for the first 5 min followed by 10 min till the end of surgery using a tympanic thermometer. Room temperature was also recorded at the start of surgery, after half an hour and after the end of surgery. After completion of surgery, patients were shifted to the recovery room. Core temperature was noted on arrival, after 30 min, 60 min and 90 min in the recovery room. Presence or absence of shivering and number and type of interventions for treating the shivering (radiant heat, intravenous pethidine 12.5 mg given when patient either complained of shivering or cold distress) were noted. Patients were discharged from recovery when the modified Alredtte's score was 9 or more, patients were able to flex their foot and had proprioception in the great toe. [9] Time to discharge was also noted. All observations were recorded and subsequently tabulated and analyzed using Student's t-test and z-test.

  Results Top

Demographic profile (age, height, weight and body mass index) of all patients in both groups I and II was statistically comparable [Table 1].
Table 1: Dermographic profile of patients

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In groups I and II, the baseline mean core temperature was 37.83 ± 0.144°C and 37.89 ± 0.113°C, respectively. There was no statistical difference between the two groups. There was a decrease in the core temperature thereafter. The decrease in core temperature from baseline (0 min) to the end of surgery (90 min) was statistically significant, with a P-value <0.01 for both groups I and II [Figure 1].
Figure 1: Trends in mean core temperature (°C) in the two study groups

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Comparison of core temperature at 5, 50, 60, 70, 80 and 90 min revealed statistically significant differences between groups I and II. The difference in the decrease in mean core temperature between the two groups was also found to be statistically significant (P < 0.01). In group I, 24 of 32 patients had a core temperature <36°C while in group II, only 13 of 32 patients had a core temperature <36°C at the time of arrival in the recovery room, and this difference in number of patients was found to be statistically significant (P < 0.05).

On arrival in the recovery room, the mean core temperature of group I patients was significantly less as compared with group II (P < 0.05) (35.49 ± 0.414°C versus 35.77 ± 0.456°C). Similarly, at 30 min after arrival in the recovery room, the mean core temperature of group I patients was 35.47 ± 0.385°C and that of group II patients was 35.99 ± 0.449°C, which was statistically significant between the two groups. The mean core temperature comparison was statistically nonsignificant after 60 and 90 min.

In group I, shivering was present in 10 patients and in group II, shivering was present in eight patients, but this difference was statistically not significant [Table 2]. In group I, intervention was needed to be carried out in 10 patients and in group II, intervention was needed in eight patients [Table 3]. The number of interventions needed was significantly higher in group I in comparison with group II. The mean discharge times in group I was 105.50 ± 9.48 min and in group II was 107.30 ± 9.21 min. In both the groups, there was no statistically significant difference in discharge time from recovery room [Table 4].
Table 2: Incidence of shivering

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Table 3: Distribution according to intervention done (radiant heat, meperidine) to prevent shivering

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Table 4: Distribution according to discharge time from recovery room

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  Discussion Top

Regional anesthesia causes redistribution of heat from the core to the periphery secondary to peripheral vasodilatation. [10] It also decreases the shivering threshold by 0.6°C, triggering vasoconstriction and shivering (above the level of block), [11] and, by blocking the autonomic control to the affected region, prevents vasoconstriction and shivering in the region of the block. [12] These effects predispose patients to the development of hypothermia during regional anesthesia, resulting in postoperative shivering, increased oxygen consumption and may also be a causative factor for neonatal hypothermia. [13],[14] Furthermore, neuraxial anesthesia also impairs behavioral thermoregulation with the result that patients often do not consciously perceive that they are hypothermic. [14]

Various methods have been tried for prevention of hypothermia in cesarean patients with variable success rate. The most important methods for preventing preoperative hypothermia are intravenous fluid warming and forced-air heating. [15] Each liter of fluid infused at ambient temperature decreases the mean body temperature by 0.25°C in an average-sized patient. [16]

Administration of room temperature intravenous fluids contributes to hypothermia; hence, infusion of warm fluids has been evaluated as an important method of heat conservation. Warm intravenous fluids can increase the core temperature by 0.5-0.7°C and lower the incidence of hypothermia. [3],[17] The results of our study make it evident that fluid warming resulted in a lesser fall of core temperature as compared with fluids given at operating room temperature. In the present study, the mean core temperature of patients in group 2 was higher than that of patients in group 2 at arrival and at 30 min. Warm intravenous fluids thus contributed to less-significant heat losses and hence attainment of the plateau phase of thermoregulatory responses.

The incidence of shivering in the two groups was not statistically significant. Similarly, no statistically significant differences in discharge times from recovery room were noted.

The results of our study are in concordance with the results obtained in the study conducted by Smith et al., who demonstrated that outpatients receiving warmed intravenous fluids were more likely to be normothermic at the end of surgery and on arrival in the recovery room than those who received fluids at operating room temperature. However, neither hypothermia nor postoperative shivering delayed discharge after these ambulatory surgical procedures. [17] They also studied the efficacy of intravenous fluid warming in patients undergoing cesarean sections under regional anesthesia and found that the fall in core temperature was less in patients who received warmed intravenous fluids (-0.8 ± 0.1) as compared with patients who received intravenous fluids at ambient temperature (-1.2 ± 0.1). The infusion of warm fluids resulted in a 0.4-0.5°C temperature advantage as compared with room temperature fluids in their study. [6]

Yokoyama et al. also confirmed this higher temperature advantage in patients receiving prewarmed fluids. In addition, APGAR scores in the neonate and umbilical pH were higher in patients receiving warmed intravenous fluids, suggesting better neonatal outcomes as well. [18] Similar results were obtained by Aglio et al., [6] wherein the authors observed that the infusion of warm fluids during cesarean delivery and in labor resulted in less fall in temperature and a significantly reduced incidence of shivering as compared with patients receiving intravenous infusions at room temperature. This advantage of a reduction in incidence of shivering was however not observed in our study. Post spinal shivering is a poorly understood entity with multiple possible etiologies. Neuraxial anesthesia per se leads to a reduction in shivering threshold. [14] The consequent hypothermia occurring during neuraxial anesthesia is attributed to multifactorial causes, with redistribution hypothermia being a leading cause. [14] This could have accounted to variance in the results of our study. Furthermore, Aglio et al. evaluated too small a study group, which could have led to a bias in their study. However, large sample sized randomized controlled trials are needed to further delineate the advantage of intravenous fluid warming to postoperative normothermia and shivering.

In conclusion, infusion of warm intravenous fluids to parturients undergoing cesarean section under regional anesthesia decreases the degree of hypothermia and is associated with a 0.25°C temperature advantage compared with intravenous fluids infused at ambient temperature of the operating room. However, it was not effective to prevent shivering and to decrease time to discharge from recovery room.

  References Top

1.Ozaki M, Kurz A, Sessler DI, Lenhardt R, Schroeder M, Moayeri A, et al. Thermoregulatory thresholds during epidural and spinal anesthesia. Anesthesiology 1994;81:282-8.  Back to cited text no. 1
2.Emerick TH, Ozaki M, Sessler DI, Walters K, Schroeder M. Epidural anesthesia increases leg temperature and decreases the shivering threshold. Anesthesiology 1994;81:289-98.  Back to cited text no. 2
3.Smith CE, Fisgus JR, Kan M, Lengen SK, Myles C, Jacobs D, et al. Efficacy of IV fluid warming in patients undergoing cesarean section with regional anesthesia. Am J Anesthesiol 2000;27:84-8.  Back to cited text no. 3
4.Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild intraoperative hypothermia increases blood loss and allogeneic transfusion requirements during total hip arthroplasty. Lancet 1996;347:289-92.  Back to cited text no. 4
5.Bhattacharya RK, Bhattacharya L, Jain RK, Aggarwal RC. Post Anesthesia shivering (PAS): A Review. Indian J Anaesth 2003;47:88-93.  Back to cited text no. 5
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6.Aglio LS, Johnson MD, Datta S, Ostheimer GW. Warm intravenous fluids reduce shivering in parturients receiving epidural analgesia. Anesthesiology 1988;69:A701.  Back to cited text no. 6
7.Imrie MM, Hall GM. Body temperature and anaesthesia. Br J Anaesth 1990;64:346-54.  Back to cited text no. 7
8.McCarroll SM, Cartwright P, Weeks SK, Donati F. Warming intravenous fluids and the incidence of shivering during caesarian sections under epidural anesthesia. Can Anesth Soc J 1986;33:S72-3.   Back to cited text no. 8
9. Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth 1995;7:89-91.  Back to cited text no. 9
10.Matsukawa T, Sessler DI, Christensen R, Ozaki M, Schroeder M. Heat flow and distribution during epidural anesthesia. Anesthesiology 1995;83:961-7.  Back to cited text no. 10
11.Kurz A, Plattner O, Sessler DI, Huemer G, Redl G, Lackner F. The threshold for thermoregulatory vasoconstriction during nitrous oxide/isoflurane anesthesia is lower in elderly than young patients. Anesthesiology 1993;79:465-9.  Back to cited text no. 11
12.Hendolin H, Poikolainen E, Mattila MA, Alhava E, Hanninin A, Puttonen E, et al. Effect of dihydroergotamine on leg blood flow during combined epidural and general anaesthesia and postoperative deep vein thrombosis after cholecystectomy. Acta Anaesthesiol Scand 1993;37:288-95.  Back to cited text no. 12
13.Vassilieff N, Rosencher N, Sessler DI, Conseiller C. Shivering threshold during Spinal Anesthesia is reduced in elderly patients. Anesthesiology 1995;83:1162-6.  Back to cited text no. 13
14.Sessler DI, Ponte J. Shivering during epidural anesthesia. Anesthesiology 1990;72:816-21.  Back to cited text no. 14
15.Kurz A, Kurz M, Poeschl G, Faryniak B, Redl G, Hackl W. Forced-air warming maintains intraoperative normothermia better than circulating-water mattresses. Anesth Analg 1993;77:89-95.  Back to cited text no. 15
16.Sessler DI. Consequences and treatment of perioperative hypothermia. Anesth Clin North Am 1994;12:425-56.  Back to cited text no. 16
17.Smith CE, Gerdes E, Sweda S, Myles C, Punjabi A, Pinchak AC, et al. Warming intravenous fluids reduces perioperative hypothermia in women undergoing ambulatory gynecological surgery. Anesth Analg 1998;87:37-41.  Back to cited text no. 17
18.Yokoyama K, Suzuki M, Shimada Y, Matsushima T, Bitto H, Sakamoto A. Effect of administration of pre-warmed intra venous fluids on the frequency of hypothermia following spinal anesthesia for cesarean delivery. J Clin Anesth 2009;21:242-8.  Back to cited text no. 18


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  [Table 1], [Table 2], [Table 3], [Table 4]

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