Prevention of peri-interventional hypothermia during endoscopic retrograde cholangiopancreatography using a forced-air heating system

Abstract

Background and study aims Perioperative hypothermia is associated with significant complications and can be prevented with forced-air heating systems (FAHS). Whether hypothermia occurs during prolonged endoscopic sedation is unclear and prevention measures are not addressed in endoscopic sedation guidelines. We hypothesized that hypothermia also occurs in a significant proportion of patients undergoing endoscopic interventions associated with longer sedation times such as endoscopic retrograde cholangiopancreaticography (ERCP), and that FAHS may prevent it.

Patients and methods In this observational study, each patient received two consecutive ERCPs, the first ERCP following current standard of care without FAHS (SOC group) and a consecutive ERCP with FAHS (FAHS group). The primary endpoint was maximum body temperature difference during sedation.

Results Twenty-four patients were included. Median (interquartile range) maximum body temperature difference was −0.9°C (−1.2; −0.4) in the SOC and −0.1°C (−0.2; 0) in the FAHS group (P < 0.001). Median body temperature was lower in the SOC compared with the FAHS group after 20, 30, 40, and 50 minutes of sedation. A reduction in body temperature of > 1°C (P < 0.001) and a reduction below 36°C (P = 0.01) occurred more often in the SOC than in the FAHS group. FAHS was independently associated with reduced risk of hypothermia (P = 0.006). More patients experienced freezing in the SOC group (P = 0.004). Hemodynmaic and respiratory stability were comparable in both groups.

Conclusions Hypothermia occurred in the majority of patients undergoing prolonged endoscopic sedation without active temperature control. FAHS was associated with higher temperature stability during sedation and better patient comfort.

Keywords

Benign strictures - ERC topics - Sedation and monitoring

• References

• 1 Sessler DI. Temperature monitoring and perioperative thermoregulation. Anesthesiology 2008; 109: 318-338
• 2 Alfonsi P, Nourredine KE, Adam F. et al. Effect of postoperative skin-surface warming on oxygen consumption and the shivering threshold. Anaesthesia 2003; 58: 1228-1234
• 3 Valeri CR, Feingold H, Cassidy G. et al. Hypothermia-induced reversible platelet dysfunction. Ann Surg 1987; 205: 175-181
• 4 Frank SM, Fleisher LA, Breslow MJ. et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA 1997; 277: 1127-1134
• 5 Kiekkas P, Fligou F, Igoumenidis M. et al. Inadvertent hypothermia and mortality in critically ill adults: Systematic review and meta-analysis. Aust Crit Care 2018; 31: 12-22
• 6 Boelhouwer RU, Bruining HA, Ong GL. Correlations of serum potassium fluctuations with body temperature after major surgery. Crit Care Med 1987; 15: 310-312
• 7 Ruetzler K, Kurz A. Consequences of perioperative hypothermia. Handb Clin Neurol 2018; 157: 687-697
• 8 Grote R, Wetz AJ, Bräuer A. et al. Prewarming according to the AWMF S3 guidelines on preventing inadvertant perioperative hypothermia 2014 : Retrospective analysis of 7786 patients. Anaesthesist 2018; 67: 27-33
• 9 Horn EP, Klar E, Höcker J. et al. Prevention of perioperative hypothermia : Implementation of the S3 guideline. Chirurg 2017; 88: 422-428
• 10 Torossian A, Bräuer A, Höcker J. et al. Preventing inadvertent perioperative hypothermia. Dtsch Arztebl Int 2015; 112: 166-172
• 11 Riphaus A, Wehrmann T, Hausmann J. et al. Update S3-guideline: "sedation for gastrointestinal endoscopy" 2014 (AWMF-register-no. 021/014). Z Gastroenterol 2016; 54: 58-95
• 12 Riphaus A, Wehrmann T. et al. S3 Guideline on Sedation in Gastrointestinal Endoscopy of the German Society for Gastroenterology and Digestive and Metabolic Diseases (DGVS). AWMF-Registernummer: 021/014. 2023
• 13 Eberhart LH, Greiner S, Geldner G. et al. Patient evaluation of postoperative recovery. An evaluation of the QoR scores in 577 patients. Anaesthesist 2002; 51: 463-466
• 14 Weiler H-WB, Fischer K, Heuser D. et al. Patientenbefragung in der Anästhesie: Der postanästhesiologische Fragebogen. Anästhesiologie & Intensivmedizin 1999; 9: 661-664
• 15 Nagelhout JJ, Elisha S. Nurse Anesthesia (6 ed.). Elsevier; 2018
• 16 Fatima H, Imperiale T. Safety profile of endoscopist-directed balanced propofol sedation for procedural sedation: an experience at a hospital-based endoscopy unit. J Clin Gastroenterol 2022; 56: e209-e215
• 17 Raina H, Prakash A, Ashraf U. et al. Is endoscopist-directed sedation for endoscopic retrograde cholangiopancreatography with balanced propofol solution (BPS) practical and safe? A prospective study from a tertiary care centre in India. Prz Gastroenterol 2021; 16: 324-329
• 18 McKenzie P, Fang J, Davis J. et al. Safety of endoscopist-directed nurse-administered balanced propofol sedation in patients with severe systemic disease (ASA class III). Gastrointest Endosc 2021; 94: 124-130
• 19 Lin OS, La Selva D, Kozarek RA. et al. Nurse-administered propofol continuous infusion sedation: a new paradigm for gastrointestinal procedural sedation. Am J Gastroenterol 2021; 116: 710-716
• 20 Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology [Anonym]. 2018; 128: 437-479
• 21 Berríos-Torres SI, Umscheid CA, Bratzler DW. et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017; 152: 784-791
• 22 American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. Last Affirmed: December 13, 2020 (last amended October 20, 2010). https://www.asahq.org/standards-and-practice-parameters/standards-for-basic-anesthetic-monitoring
• 23 World Health Organization. A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization.
• 24 maintaining normal body temperature (normothermia). 2018 https://www.ncbi.nlm.nih.gov/books/NBK536436/
• 25 Ng SF, Oo CS, Loh KH. et al. A comparative study of three warming interventions to determine the most effective in maintaining perioperative normothermia. Anesth Analg 2003; 96: 171-176
• 26 Horn EP, Bein B, Böhm R. et al. The effect of short time periods of pre-operative warming in the prevention of peri-operative hypothermia. Anaesthesia 2012; 67: 612-617
• 27 Alderson P, Campbell G, Smith AF. et al. Thermal insulation for preventing inadvertent perioperative hypothermia. Cochrane Database Syst Rev 2014;