Interesting case of hypothermia

Specialties CRNA

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I thought some of you would be interested in a case I had this week. The patient is 42 years old, excellent health, no meds, no allergies, never had surgery or anesthesia, scheduled for a mastopexy and large volume liposuction. Labs normal, including thyroid studies. She told me that she is always cold and has the heat on even in the summer.

Shortly after induction and intubation with propofol, fentanyl, cisatracrium, I noted her temp going down from 35 (esophageal). Anesthesia was maintined with isoflurane 0.5-0.75%, nitrous and oxygen. No additional muscle relaxant or narcotic. Tumescent local anesthesia for the liposuction of 3 liters of dilute local in a warmed solution. Much of her body was exposed for the surgery, because we had two teams of surgeons working--one on the breasts, the other on the body. Her temp continued to drop to 30.9, despite warming iv fluids, using the forced air warmed whereever I could on the body. I used several different temp devices to confirm the temperature. I asked the surgeons not to complete all of the liposuction because of the temp drop.

She was a little slow to recover from anesthesia, and it took our night nurse about 3 hours of warmed solutions, body warmer and hot blankets to get her temp anywhere close to normal.

I saw the patient two days post-op and she is doing great and wants to know when we are going to do the remaining liposuction. Again, she told me that she has always been very cold.

Any thoughts or comments.

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Hi, I was wondering -maybe she had some hypothalmic dysfynction? I work on a medical care unit for MR/DD patients and I have alot of hypothermic episodes, but is due to altered brain patho. Just an idea, she should have that checked into, especially since it is a consistently occuring problem. Did you suggest this to her?

I thought some of you would be interested in a case I had this week. The patient is 42 years old, excellent health, no meds, no allergies, never had surgery or anesthesia, scheduled for a mastopexy and large volume liposuction. Labs normal, including thyroid studies. She told me that she is always cold and has the heat on even in the summer.

Shortly after induction and intubation with propofol, fentanyl, cisatracrium, I noted her temp going down from 35 (esophageal). Anesthesia was maintined with isoflurane 0.5-0.75%, nitrous and oxygen. No additional muscle relaxant or narcotic. Tumescent local anesthesia for the liposuction of 3 liters of dilute local in a warmed solution. Much of her body was exposed for the surgery, because we had two teams of surgeons working--one on the breasts, the other on the body. Her temp continued to drop to 30.9, despite warming iv fluids, using the forced air warmed whereever I could on the body. I used several different temp devices to confirm the temperature. I asked the surgeons not to complete all of the liposuction because of the temp drop.

She was a little slow to recover from anesthesia, and it took our night nurse about 3 hours of warmed solutions, body warmer and hot blankets to get her temp anywhere close to normal.

I saw the patient two days post-op and she is doing great and wants to know when we are going to do the remaining liposuction. Again, she told me that she has always been very cold.

Any thoughts or comments.

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Very interesting case, Yoga. How warm was the room temp? It's like pulling teeth in my hospital for the staff in the room to increase the room temp b/c god forbid, they should be a little warm. I used to enjoy a day in the burn OR so I could be warm for just 1 day..

skipaway

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Very interesting case, Yoga. How warm was the room temp? It's like pulling teeth in my hospital for the staff in the room to increase the room temp b/c god forbid, they should be a little warm. I used to enjoy a day in the burn OR so I could be warm for just 1 day..

skipaway

The OR temp was 68 F. Liposuction is a physically demanding procedure for the surgeons and they get hot quickly. We warmed up the room as soon as we could and made the surgeons sweat.

As an aside, I also hate cold operating rooms and think they are usually unnecessary. It is a battle I save for the really important cases such as this one.

Yoga

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I think it would be reasonably prudent to have a basal TSH and T4 done to rule out hypothalamic dysfunction.

Maybe the combination of low ambient temperature, prolonged exposure, and anesthesia are more likely the cause though.

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Sounds very much like Wilson's Syndrome.

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Sounds very much like Wilson's Syndrome.

wilson's syndrome is widely considered as a BS diagnosis....

"The American Thyroid Association has found no scientific evidence supporting the existence of "Wilson's syndrome."

http://www.thyroid.org/professionals/publications/statements/99_11_16_wilsons.html

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I think it would be reasonably prudent to have a basal TSH and T4 done to rule out hypothalamic dysfunction.

Maybe the combination of low ambient temperature, prolonged exposure, and anesthesia are more likely the cause though.

I know but he/she said it was a recurring prob with this patient, at home having heat on in summer.

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Shortly after induction and intubation with propofol, fentanyl, cisatracrium, I noted her temp going down from 35 (esophageal). Anesthesia was maintined with isoflurane 0.5-0.75%, nitrous and oxygen. No additional muscle relaxant or narcotic. Tumescent local anesthesia for the liposuction of 3 liters of dilute local in a warmed solution. Much of her body was exposed for the surgery, because we had two teams of surgeons working--one on the breasts, the other on the body. Her temp continued to drop to 30.9, despite warming iv fluids, using the forced air warmed whereever I could on the body. I used several different temp devices to confirm the temperature. I asked the surgeons not to complete all of the liposuction because of the temp drop.

Any thoughts or comments.

Here's my take - I think all of the answers are within your posts.

"Tumescent local anesthesia for the liposuction of 3 liters of dilute local in a warmed solution..." Warmed when? How long were they hanging in the cold OR before use? What was the temp as it entered the patient's body? If it was less than 37degC, you're losing ground.

"Much of her body was exposed for the surgery..." Bingo. She's losing heat faster than you can replace it. Exposed, add prep solution (doesn't mattter if it's warmed or not, it still evaporates), allow heat to evaporate continuously for X number of hours, etc. All that works against you.

"...despite warming iv fluids..." It is physically impossible to warm a patient with warmed IV fluids. It's simple physics (remember specific heat?) It can't be done. You can slow down the rate of patient cooling a little, but you can't warm them.

"...using the forced air warmed whereever I could on the body..." Obviously the right thing to do. But if your plastics cases are like mine, that means a warming blanket on the legs. Add a warm blanket around the head, and that's about as good as you can get for these kinds of cases.

I think this is all simple physics - your patient got colder faster than you could replace the heat they lost. Thyroid? Nah. Other esoteric disease process? Nah. I think your surgeons need to pay more attention to the patient's well-being and less to their own comfort. I think you pretty much did what you could do - except I would have stopped well before the time they hit 30.9degC on an elective plastic surgery case.

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not to mention that there are studies in the SURGICAL literature that show lower infection rates, less post-op hematoma formation, etc... when patients are maintained euthermic.... when surgeons want the room temp down, I only allow it if I am satisfied w/ the patients core temp, otherwise i say NO .... and when they bug me more about it, I tell them to read up on their literature in their own journals... and if they continue to bug me, i tell them to deal with it, and if it is really that bad and annoying for them, they should step out, get a cold glass of water and come back refreshed for more... If burn trauma surgeons can do it for 12 hours straight then so can anybody...

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Thank God for a clinical post! ....VERY interesting...thanks Yoga, et al...........wish I had more to offer, but sure looks like its being covered. We don't talk enough about hypothermia.....

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I would agree that there has been a lack of clinical posts lately.

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