Core temperature falls during laparotomy in infants with necrotizing enterocolitis

Risk factors for intraoperative hypothermia in infants during general anesthesia: A retrospective study

This study aimed to determine the incidence and evaluate the risk factors and outcomes of intraoperative hypothermia (IH) during general anesthesia in infants. Retrospective analysis of prospectively collected data. A total of 754 infants younger than 1 year old who underwent surgery under general anesthesia were included. Intraoperative body temperature fluctuations, surgical and anesthetic data, postoperative complications, and infant outcomes were recorded. Logistic regression algorithms were used to evaluate potential risk factors. Among the 754 infants, 47.88% developed IH (<36 °C) and 15.4% of them experienced severe hypothermia (<35 °C). The average lowest temperature in hypothermia patients was 35.06 ± 0.69°C with a duration of 82.23 ± 50.59 minutes. Neonates tended to experience hypothermia (37.7% vs 7.6%, P < .001) and prematurity was more common in patients with IH (29.4% vs 16.8%, P < .001). Infants with hypothermia experienced a longer length of stay in the post anesthesia care units and intensive care units, postoperative hospitalizations, and tracheal extubation as well as a higher rate of postoperative hemorrhage than those with normothermia (all P < .05). Several factors were proved to be associated with an increased risk of IH after multivariate analysis: neonate (odds ratio [OR] = 3.685, 95% CI 1.839-7.382), weight (OR = 0.599, 95% CI 0.525-0.683), American society of anesthesiologists (OR = 3.418, 95% CI 2.259-5.170), fluid > 20 mL/kg (OR = 2.380, 95% CI 1.389-4.076), surgery time >60 minutes (OR = 1.785, 95% CI 1.030-3.093), and pre-warming (OR = 0.027, 95% CI 0.014-0.052). This retrospective study found that neonates, lower weight, longer surgery times, more fluid received, higher American society of anesthesiologists stage, and no pre-warming were all significant risk factors for IH during general anesthesia in infants.

Risk factors and outcomes of intraoperative hypothermia in neonatal and infant patients undergoing general anesthesia and surgery

Objective

The incidence of intraoperative hypothermia remains high in pediatric patients during anesthesia and surgery even though core body temperature monitoring and warming systems have been greatly improved in recent years. We analyzed the risk factors and outcomes of intraoperative hypothermia in neonates and infants undergoing general anesthesia and surgery.

Methods

The data on the incidence of intraoperative hypothermia, other clinical characteristics, and outcomes from electronic records of 1,091 patients (501 neonates and 590 infants between 28 days and 1 year old), who received general anesthesia and surgery, were harvested and analyzed. Intraoperative hypothermia was defined as a core temperature below 36°C during surgery.

Results

The incidence of intraoperative hypothermia in neonates was 82.83%, which was extremely higher than in infants (38.31%, p < 0.001)-the same as the lowest body temperature (35.05 ± 0.69°C vs. 35.40 ± 0.68°C, p < 0.001) and the hypothermia duration (86.6 ± 44.5 min vs. 75.0 ± 52.4 min, p < 0.001). Intraoperative hypothermia was associated with prolonged PACU, ICU, hospital stay, postoperative bleeding, and transfusion in either age group. Intraoperative hypothermia in infants was also related to prolonged postoperative extubation time and surgical site infection. After univariate and multivariate analyses, the age (OR = 0.902, p < 0.001), weight (OR = 0.480, p = 0.013), prematurity (OR = 2.793, p = 0.036), surgery time of more than 60 min (OR = 3.743, p < 0.001), prewarming (OR = 0.081, p < 0.001), received >20 mL/kg fluid (OR = 2.938, p = 0.004), and emergency surgery (OR = 2.142, p = 0.019) were associated with hypothermia in neonates. Similar to neonates, age (OR = 0.991, p < 0.001), weight (OR = 0.783, p = 0.019), surgery time >60 min (OR = 2.140, p = 0.017), pre-warming (OR = 0.017, p < 0.001), and receive >20 mL/kg fluid (OR = 3.074, p = 0.001) were relevant factors to intraoperative hypothermia in infants along with the ASA grade (OR = 4.135, p < 0.001).

Conclusion

The incidence of intraoperative hypothermia was still high, especially in neonates, with a few detrimental complications. Neonates and infants each have their different risk factors associated with intraoperative hypothermia, but younger age, lower weight, longer surgery time, received more fluid, and no prewarming management were the common risk factors.

Perioperative Hypothermia in Children

Background: First described by paediatric anaesthesiologists, perioperative hypothermia is one of the earliest reported side effects of general anaesthesia. Deviations from normothermia are associated with numerous complications and adverse outcomes, with infants and small children at the highest risk. Nowadays, maintenance of normothermia is an important quality metric in paediatric anaesthesia. Methods: This review is based on our collection of publications regarding perioperative hypothermia and was supplemented with pertinent publications from a MEDLINE literature search. Results: We provide an overview on perioperative hypothermia in the paediatric patient, including definition, history, incidence, development, monitoring, risk factors, and adverse events, and provide management recommendations for its prevention. We also summarize the side effects and complications of perioperative temperature management. Conclusions: Perioperative hypothermia is still common in paediatric patients and may be attributed to their vulnerable physiology, but also may result from insufficient perioperative warming. An effective perioperative warming strategy incorporates the maintenance of normothermia during transportation, active warming before induction of anaesthesia, active warming during anaesthesia and surgery, and accurate measurement of core temperature. Perioperative temperature management must also prevent hyperthermia in children.

Effects of intraoperative temperatures on postoperative infections in infants and neonates

BACKGROUND

Perioperative hypothermia has been shown to increase surgical site infection (SSI) rates in adults. We sought to characterize whether intraoperative hypothermia or hyperthermia is associated with postoperative infections in infants.

METHODS

We conducted a retrospective review of patients ≤6 months old who underwent surgical procedures from November 2013 to October 2015 at a Level I ACS Children's Surgical Center. The outcome was infections within 30 days after operation, with particular attention to SSI. Data obtained included weight and age at surgery, American Society of Anesthesiologists (ASA) physiologic status, wound class, case length, blood transfusion within 72 h of surgery, and administration of prophylactic antibiotics. Temperatures were classified as hypothermia (T < 36 °C), normothermia (T = 36.0 to 37.9 °C), and hyperthermia (T ≥ 38 °C).

RESULTS

The 885 patients had 25 SSIs (2.8%) and 11 nonsurgical site infections (1.2%). On univariate analysis, weight at surgery, higher ASA, perioperative transfusions, and longer case length were associated with higher rate of SSI. Higher median T_high, higher median T _low, and any hyperthermia were associated with higher rate of SSI. On multivariable logistic regression adjusted analyses, hyperthermia at any time during the case was associated with SSI (OR 3.47, [95% CI 1.34, 9.04], p = 0.011). Transfusions were also associated with higher SSI rates (OR 3.60 [95% CI, 1.28, 10.3], p = 0.016).

CONCLUSIONS

Intraoperative hyperthermia is associated with increased SSI rates in infants.

LEVEL OF EVIDENCE

III.

Conservative treatment of iatrogenic perforations caused by gastric tubes in extremely low birth weight infants

BACKGROUND

Iatrogenic gastrointestinal perforations are rare, but life-threatening events in preterm infants.

AIM

Aim of the study was to report on incidence, management, morbidity, and mortality.

STUDY DESIGN

This was a retrospective analysis performed at a tertiary neonatal intensive care unit in Vienna, Austria.

SUBJECTS

Extremely low birth weight infants (ELBW, birth weight < 1000 g) with perforations of the upper gastrointestinal tract (GIT) caused by gastric tubes were included.

OUTCOME MEASURES

All ELBW infants born within the 6-year study period were identified and their discharge summaries or notes were screened for esophageal and gastric perforations. Data on incidence, management of GIT perforations, morbidity, and mortality were obtained.

RESULTS

During a 6-year study period 646 ELBW infants were analyzed. Incidence of perforations was 1.1% (n = 7/646). Median gestational age was 23 + 3 (range: 23 + 0-24 + 5). Perforations occurred on the third day of life (=median, range: day 2-14) and were primarily managed conservatively. Enteral feeding was stopped for 6 days (range: 4-13 days), antibiotic therapy administered for 16 days (range: 8-22 days). In one infant, gastrorrhaphy was performed.

CONCLUSIONS

Conservative treatment of upper GIT perforations led to spontaneous recovery without major complications in 85.7%.

Neurodevelopmental considerations in surgical necrotizing enterocolitis

The majority of surviving infants with surgical necrotizing enterocolitis (NEC) will have some degree of neurodevelopmental impairment. The impact of specific medial and surgical treatments for infants with severe NEC remains largely unknown but is being actively investigated. It is incumbent upon all providers caring for these infants to continue to focus on long term neurodevelopmental outcomes and to develop more widespread methods of neurodevelopmental assessment.

Ileostomy Complications in Infants less than 1500 grams - Frequent but Manageable

Background: In very low birth weight infants abdominal emergency surgery may result in ileostomy formation. We observed a frequent stoma complications in these patients. This retrospective analysis put light on ileostomy-related problems and complications in very low birth weight (VLBW) infants.

Materials and Methods: In a seven-year retrospective chart review (2008 - 2014) infants with ileostomy formation weighing less than 1500 grams at time of operation were identified and reviewed. Data analysis included demographic data, complications and short term outcomes.

Results: Thirty patients were included. Ileostomy was formed for spontaneous intestinal perforation (SIP) (n=17), meconium obstruction of prematurity (MOP) (n=6), midgut volvulus (MV) (n=5), necrotizing enterocolitis (NEC) (n=1) and Hirschsprung’s disease (HD) (n=1). Three patients died before ileostomy reversal was considered. In seven patients planned ileostomy reversal was done. Twenty infants had stoma related complications (stoma prolapse, prestomal obstruction, stoma retraction, high output stoma, peristomal skin excoriation, and stomal ischemia). Complications did not correlate with underlying diseases. Stomal complications necessitated earlier stoma reversal (mean 62 days). Postoperative complications after stoma reversal occurred in three children (wound dehiscence, adhesion ileus, anastomotic stricture).

Conclusions: Although ileostomy related complications are frequent in very low birth weight infants, mortality is low. Morbidity is manageable.

Predictors of unfavorable thermal outcome during newborn emergency retrievals

OBJECTIVE

Maintenance of normal body temperature is a challenge during transports. We aimed to identify predisposing factors for unfavorable thermal outcome during emergency retrievals of neonates.

METHODS

Demographic data and clinical variables for transports performed over a 2-year period were extracted from the Newborn Emergency Transport Service (Victoria, Australia) database. Arrival temperatures outside normothermia (36.5°-37.5°C) were defined as an unfavorable outcome.

RESULTS

Normothermia on arrival at the receiving hospital was achieved in 78% of 1,261 transports. The strongest predictor of unfavorable thermal outcome was an abnormal temperature at the start of the retrieval (odds ratio [OR] = 8.04; 95% confidence interval [CI], 5.91-10.95; P < .001) followed by very low weight on transport (< 1,500 g; OR = 2.49; 95% CI, 1.63-3.80; P < .001) and respiratory support (OR = 1.81; 95% CI, 1.29-2.54; P = .001). Medications (eg, inotropes and sedation/muscle relaxation) or central/peripheral venous/arterial lines were not significant predictors of outcome when temperature at retrieval start, weight at transport, and respiratory support were adjusted as cofactors. Mode of transport (road, fixed wing, or rotary wing aircraft) and outside temperature were not associated with thermal outcome.

CONCLUSION

Abnormal temperature at the start of the retrieval, very low transport weight, and respiratory support were strong predictors of unfavorable thermal outcome during neonatal emergency transports.