Effect of hypothermia on haemostasis and bleeding risk: a narrative review

Optimal Temperature of Irrigation Fluid for Hemostasis in Neurosurgery: A Narrative Literature Review

BACKGROUND

 Hemostasis in neurosurgery is crucial to patient and surgery outcomes, with many techniques developed for this. One area that is not appropriately characterized despite continuous anecdotal evidence the temperature of the irrigation fluid (IF) used and its effects on stemming hemorrhages. Given the ubiquitous use of IF in neurosurgery for clearing blood from the surgical field, it is important to explore its role as a hemostat and whether or not the temperature of the IF influences its hemostatic capacity. This review explored the literature for an optimal IF temperature for hemostasis in neurosurgery.

METHODS

 Database searches were conducted using MEDLINE, Scopus, Web of Science, and CINAHL, with citation chaining occurring where applicable. Standard terms around neurosurgery, hemostasis, and irrigation were used.

RESULTS

 Seven articles were identified. No optimal temperature for hemostasis could be confidently synthesized from the literature owing to lack of primary investigation on the subject. After collating available information into common themes, it is suggested that that temperatures >38°C are preferred.

CONCLUSION

 The literature in this area is limited. Despite a lack of applicable systematic investigation on the topic, by exploring the physiology of hemostasis and IF, best practice guidelines for IF, and the literature on the role of the temperature of IF in other surgical specialties, it is suggested that a temperature in the range of 38 to 40°C would be most applicable to a value optimal for neurosurgery.

Retrospective analysis of the effects of hypocalcemia in severely injured trauma patients

BACKGROUND

It has been suggested that the Lethal Triad be modified to include hypocalcemia, coined as the Lethal Diamond. Hypocalcemia in trauma has been attributed to multiple mechanisms, but new evidence suggests that traumatic injury may result in the development of hypoCa independent of blood transfusion. We hypothesize that hypocalcemia is associated with increased blood product requirements and mortality.

METHODS

A retrospective study of 1,981 severely injured adult trauma patients from 2016 to 2019. Ionized calcium (iCa) levels were obtained on arrival and subjects were categorized by a threshold iCa level of 1.00 mmol/L and compared. Univariable and multivariable logistic regression analysis was performed.

RESULTS

The hypocalcemia (iCa <1.00 mmol/L) group had increased rate of overall (p = 0.001), 4-hr (p = 0.007), and 24-hr (p = 0.003) mortality. There was no difference in prehospital transfusion volume between groups (p = 0.25). Hypocalcemia was associated with increased blood product requirements at 4 h (p <0.001), 24 h (p <0.001), and overall hospital length of stay (p <0.001). Logistic regression analysis showed increased odds of 4-hour mortality (OR 0.077 [95 % CI 0.011, 0.523], p = 0.009) and 24-hour mortality (OR 0.121 [95 % CI 0.019, 0.758], p = 0.024) for every mmol/L increase in iCa.

CONCLUSIONS

This study shows the association of hypoCa and traumatic injury. Severe hypoCa was associated with increased odds of early and overall mortality and increased blood product requirements. These results support the need for future prospective trials assessing the role of hypocalcemia in trauma.

Immediate Platelet Inhibition Strategy for Comatose Out-of-Hospital Cardiac Arrest Survivors Undergoing Percutaneous Coronary Intervention and Mild Therapeutic Hypothermia

Background: Comatose survivors of out-of-hospital cardiac arrest (OHCA) undergoing percutaneous coronary intervention (PCI) and target temperature management (TTM) are at increased risk of stent thrombosis (ST), partly due to delayed platelet inhibition even with more potent P2Y12 agents. We hypothesized that periprocedural cangrelor would induce immediate platelet inhibition, bridging the "P2Y12 inhibition gap". Methods: In our pilot study, we randomized 30 comatose OHCA patients undergoing PCI and TTM (32-34 °C) into cangrelor and control groups. Both groups received unfractioned heparin, acetylsalicylic acid, and ticagrelor via enteral tube. The cangrelor group also received an intravenous bolus of cangrelor followed by a 4 h infusion. Platelet inhibition was measured using VerifyNow® and Multiplate® ADP at baseline and 1, 3, 5, and 8 h post PCI. Results: Patient characteristics did not differ between groups. VerifyNow® showed significantly decreased platelet reactivity with cangrelor at 1 h (30 vs. 221 PRU; p < 0.001) and 3 h (24 vs. 180 PRU; p < 0.001), with differences at 5 and 8 h. Similarly, the proportion of patients with high on-treatment platelet reactivity (HPR) in the cangrelor group was significantly lower at 1 h (0% vs. 67%; p < 0.001) and 3 h (0% vs. 47%; p = 0.007). Multiplate® ADP was also decreased at 1 h (14 vs. 48 U; p < 0.001) and 3 h (11 vs. 42 U; p = 0.001), with no difference at 5 and 8 h. The occurrence of bleeding events was similar in both groups. Conclusions: Cangrelor safely induced immediate and profound platelet inhibition. We observed no significant drug-drug interaction with ticagrelor.

The Relationship Between Transfusion in Cardiac Surgery Patients and Adverse Outcomes

OBJECTIVES

To understand if red blood cell (RBC) transfusions are independently associated with a risk of mortality, prolonged intubation, or infectious, cardiac, or renal morbid outcomes.

DESIGN

A retrospective review.

SETTING

A single-institution university hospital.

PARTICIPANTS

A total of 2,458 patients undergoing coronary bypass artery graft and/or valvular surgery from July 2014 through January 2018.

INTERVENTIONS

No interventions were done.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the occurrence of an adverse event or prolonged intubation. Infectious, cardiac, and renal composite outcomes were also defined. These composites, along with mortality, were analyzed individually and then combined to form the "any adverse events" composite. Preoperative demographic and intraoperative parameters were analyzed as univariate risk factors for adverse outcomes. Logistic regression was used to screen variables, with a p value criterion of p < 0.05 for entry into the model selection procedure. A backward selection algorithm was used with variable entry and retention criteria of p < 0.05 to select the final multivariate model. Multivariate logistic regression models were used to determine whether there was an association between the volume of RBC transfusion and the defined adverse event after adjusting for covariates. A p value < 0.01 was considered statistically significant in the final model of each aim to adjust for multiple comparisons. The final logistic models for each of the following outcomes indicate an increased risk of that outcome per each additional unit of RBC transfused. For prolonged intubation, the odds ratio (OR) was 1.493 (p < 0.0001), OR = 1.358 (p < 0.0001) for infectious composite outcomes, OR = 1.247 (p < 0.0001) for adverse renal outcomes, and OR = 1.467 (p < 0.0001) for any adverse event.

CONCLUSIONS

The authors demonstrated a strong independent association between RBC transfusion volume and adverse outcomes after cardiac surgery. Efforts should be undertaken, such as preoperative anemia management and control of coagulopathy, in order to minimize the need for RBC transfusion.

Long-term survival after cardiac arrest in patients undergoing emergent coronary angiography

AIM

To determine long-term survival of patients after cardiac arrest undergoing emergent coronary angiography and therapeutic hypothermia.

METHODS

We analysed data from patients treated within the regional STEMI Network from January 2015 to December 2020. The primary endpoint was all-cause mortality at median follow-up. Secondary endpoints were periprocedural complications (arrhythmias, pulmonary edema, cardiogenic shock, mechanical complication, stent thrombosis, reinfarction, bleeding) and 6-month all-cause death. A landmark analysis was performed, studying two time periods; 0-6 months and beyond 6 months.

RESULTS

From a total of 24,125 patients in the regional STEMI network, 494 patients who suffered from cardiac arrest were included and divided into two groups: treated with (n = 119) and without therapeutic hypothermia (n = 375). At median follow-up (16.0 [0.2-33.3] months), there was no difference in the adjusted mortality rate between groups (51.3 % with hypothermia vs 48.0 % without hypothermia; HRadj1.08 95%CI [0.77-1.53]; p = 0.659). There was a higher frequency of bleeding in the hypothermia group (6.7 % vs 1.1 %; ORadj 7.99 95%CI [2.05-31.2]; p = 0.002), without difference for the rest of periprocedural complications. At 6-month follow-up, adjusted all-cause mortality rate was similar between groups (46.2 % with hypothermia vs 44.5 % without hypothermia; HRadj1.02 95%CI [0.71-1.47]; p = 0.900). Also, no differences were observed in the adjusted mortality rate between 6 months and median follow-up (9.4 % with hypothermia vs 6.3 % without hypothermia; HRadj2.02 95%CI [0.69-5.92]; p = 0.200).

CONCLUSIONS

In a large cohort of patients with cardiac arrest within a regional STEMI network, those treated with therapeutic hypothermia did not improve long-term survival compared to those without hypothermia.

Effect of prewarmed crystalloid fluids and an in-line fluid warming device on fluid outflow temperatures at ambient temperatures of 21-22°C and 3.5°C

Equine veterinarians frequently treat patients in non-climate-controlled (i.e., hospitalized) settings. In colder environments, intravenous (IV) fluid administration can contribute to patient hypothermia. The objective of this study was to evaluate three IV fluid warming mechanisms to determine their effect on fluid outflow temperatures at ambient temperatures of 21-22°C and 3.5°C. In this study, fluid outflow temperatures were measured using three warming mechanisms: (1) pre-warmed fluids at 42°C, (2) an in-line warming device placed 163 cm away from the Luer-lock fluid line adaptor (location 1) on the fluid line, and (3) an in-line warming device placed 88 cm away from the Luer-lock fluid line adaptor (location 2) on the fluid line. These warming mechanisms were compared to outflow temperatures measured using no warming mechanism at ambient temperatures of 21-22°C and 3.5°C with flow rates of ∼12 L/hour (gravity flow bolus) and 999 mL/hour. All outflow temperatures were measured with a thermistor. At ∼12L/hour, the use of pre-warmed fluids increased outflow temperatures at both ambient temperatures of 21-22°C and 3.5°C ambient temperatures and an in-line warming device placed at location 1 significantly increased outflow temperatures in 3.5°C ambient temperatures. At 999 mL/hour, use of pre-warmed fluids or an in-line warming device, placed at either location, increased outflow temperatures at ambient temperatures of 21°C or 3.5°C.

Inadvertent perioperative hypothermia and surgical site infections after liver resection

BACKGROUND

In the overall surgical population, inadvertent perioperative hypothermia has been associated with an increased incidence of surgical site infection (SSI). However, recent clinical trials did not validate this notion. This study aimed to investigate the potential correlation between inadvertent perioperative hypothermia and SSIs following liver resection.

METHODS

This retrospective cohort study included all consecutive patients who underwent liver resection between January 2019 and December 2021 at the First Affiliated Hospital, Zhejiang University School of Medicine. Perioperative temperature managements were implemented for all patients included in the analysis. Estimated propensity score matching (PSM) was performed to reduce the baseline imbalances between the normothermia and hypothermia groups. Before and after PSM, univariate analyses were performed to evaluate the correlation between hypothermia and SSI. Multivariate regression analysis was performed to determine whether hypothermia was an independent risk factor for postoperative transfusion and major complications. Subgroup analyses were performed for diabetes mellitus, age > 65 years, and major liver resection.

RESULTS

Among 4000 patients, 2206 had hypothermia (55.2%), of which 150 developed SSI (6.8%). PSM yielded 1434 individuals in each group. After PSM, the hypothermia and normothermia groups demonstrated similar incidence rates of SSI (6.3% vs. 7.0%, P = 0.453), postoperative transfusion (13.3% vs. 13.7%, P = 0.743), and major complications (9.0% vs. 10.1%, P = 0.309). Univariate regression analysis revealed no significant effects of hypothermia on the incidence of SSI in the group with the highest hypothermia exposure [odds ratio (OR) = 1.25, 95% confidence interval (CI): 0.84-1.87, P = 0.266], the group with moderate exposure (OR = 1.00, 95% CI: 0.65-1.53, P = 0.999), or the group with the lowest exposure (OR = 1.11, 95% CI: 0.73-1.65, P = 0.628). The subgroup analysis revealed similar results. Regarding liver function, patients in the hypothermia group demonstrated lower γ-glutamyl transpeptidase (37 vs. 43 U/L, P = 0.001) and alkaline phosphatase (69 vs. 72 U/L, P = 0.016). However, patients in the hypothermia group exhibited prolonged activated partial thromboplastin time (29.2 vs. 28.6 s, P < 0.01).

CONCLUSIONS

In our study of patients undergoing liver resection, we found no significant association between mild perioperative hypothermia and SSI. It might be due to the perioperative temperature managements, especially active warming measures, which limited the impact of perioperative hypothermia on the occurrence of SSI.

Using infrared cameras in drones to detect bleeding events

BACKGROUND

Hemorrhage is one of the main causes of death in trauma. Critical bleeding in patients needs to be detected as soon as possible to save the patient. Drones are gaining increasing importance in emergency services and can support rescue forces in accident scenarios such as a mass casualty incident.

METHODS

In this study, a simulated pelvic hemorrhage was detected using a drone from 7 m above the ground over a time span of 30 s.

RESULTS

The results allow a good detection of the pelvic hemorrhage. Nevertheless, the simulated blood cools down quickly. After 30 s, there was no significant temperature difference compared to the rest of the body. At this point, further assessment is only possible via the RGB image.

CONCLUSION

The findings suggest that bleeding from an open and continuously bleeding wound would most likely be detectable using the drone's thermal imaging camera, even over a longer period of time.

Hypothermia as an Adjunctive Therapy in Cardiogenic Shock: A Systematic Review and Meta-Analysis

In the setting of out-of-hospital cardiac arrest, therapeutic hypothermia (TH) has been shown to improve clinical outcomes. However, trials showing the advantage of TH did not include patients with cardiogenic shock (CS). We performed a comprehensive literature search for studies that evaluated the efficacy and safety of adjunctive TH compared with the standard of care (SOC) in patients with CS. The primary outcome was the mortality rate (in-hospital, short-, and mid-term). The secondary outcomes were the TH-related complications, duration of Intensive Care Unit (ICU) stay, duration of mechanical ventilation (MV-days), and improvement in cardiac function. Relative risk (RR) or the standardized mean difference (SMD) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model. A total of 7 clinical studies (3 RCTs included), and 712 patients (341 in the TH group and 371 in the SOC group) were included. As compared with the SOC, TH was not associated with a statistically significant improvement in the in-hospital (RR: 0.73%, 95% CI: 0.51-1.03; p = 0.08), short-term (RR: 0.90%, 95% CI: 0.75-1.06; p = 0.21), or mid-term (RR: 0.93%, 95% CI: 0.78-1.10; p = 0.38) mortality rates. Despite the improvement in the cardiac function in the TH group (SMD: 1.08, 95% CI: 0.02-2.1; p = 0.04), the TH strategy did not significantly shorten the MV days, or the ICU stay (p-values >0.05). Finally, there was a trend toward higher risks for infection, major bleeding, and the need for blood transfusion in the TH group. According to our meta-analysis of published clinical studies, TH is not beneficial in patients with CS and has a marginal safety profile. Larger-scale RCTs are needed to further clarify our results.

Prevalence of Postoperative Hypothermia in the Post-anesthesia Care Unit

Background

Unwanted postoperative hypothermia is an unpleasant event that can cause various complications.

Objectives

As this serious complication and its provoking causes have not been investigated sufficiently, this study was designed and conducted to determine the prevalence of hypothermia and its associated factors in the post-anesthesia care unit after elective surgery.

Methods

Four hundred patients undergoing elective surgeries were enrolled in the present cross-sectional research after termination of surgery and at the time of arrival at the post-anesthesia care unit of Poursina Public University Hospital. The tympanic membrane temperature was measured and recorded at the time of arrival at the post-anesthesia care unit and every 30 minutes after arrival. The required data were collected in a researcher-made checklist and analyzed after entering the SPSS software version 25.

Results

Considering the 5% error, it can be said that the prevalence of hypothermia in patients undergoing elective surgery ranges from 20 to 28% at the time of arrival at the post-anesthesia care unit and 18.5 to 26% 30 minutes after arrival.

Conclusions

More than a quarter of patients experienced hypothermia following elective surgery. Therefore, appropriate treatment and control measures are necessary to manage this complication, particularly in patients with predisposing risk factors and comorbidities.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

The Challenges of Spinal Surgery Requiring Ventral Decubitus in the Critical Trauma Patient on Extracorporeal Membrane Oxygenation: A Case Report

Extracorporeal membrane oxygenation (ECMO) provides a bypass of the lungs, ensuring blood oxygenation and carbon dioxide removal in cases of respiratory failure. The nature of the device itself creates many perioperative challenges, including fluid management and the management of anticoagulation. Surgery via the posterior approach for an unstable spinal fracture requiring the ventral decubitus position comes with its own set of difficulties, among which are the need for stability and craniocaudal alignment when rotating the patient, the risk of increased abdominal pressure, and the damage to vulnerable soft tissues like the eyes, nose, and others. The combination of these two situations creates a synergistic effect, which adds to the difficulty of the management of the situation and requires a personalized, multidisciplinary approach. We present a case of a critical trauma patient who was on venovenous ECMO as a consequence of refractory respiratory hypoxemia with an unstable mid-thoracic spinal fracture requiring surgical intervention via the posterior approach (demanding intra-operative ventral decubitus).

Efficacy of Continuous Suctioning in Adenoidectomy Haemostasis-Clinical Study

Introduction: Adenoidectomy is often the first major surgical challenge for the child's haemostatic system, and controlling intraoperative bleeding can be a challenge for the surgeon. Different methods have been used intraoperatively by surgeons in order to enhance haemostasis. The cold air effect (continuous suctioning) has been used by some surgeons during adenoidectomy; however, no documentation of its haemostatic effect has been made. Objectives: Our prospective randomised controlled study enrolled a sample of 140 children undergoing adenoidectomy, and we studied the effect of continuous suctioning on the duration of haemostasis in paediatric adenoidectomy. Materials and Methods: We evaluated the effect of using continuous suctioning during haemostasis at the end of adenoidectomy procedures, comparing variables such as total surgery time, total haemostasis time, and intraoperative blood loss, between two groups: 70 adenoidectomy procedures where no continuous suctioning was used to enhance haemostasis versus the other 70 patients where continuous suctioning was the haemostatic method employed. RESULTS: After statistical analysis of the recorded data, we found that the total duration of adenoidectomy, the duration of haemostasis in adenoidectomy, and the intraoperative blood loss were significantly lower in patients in whom cold air was used for haemostasis. Intraoperative haemostasis failure (and consequent use of electrocautery for haemostasis) was more frequent in patients in whom no suctioning was used; as for the rates of postoperative primary bleeding after adenoidectomy, they were similar in both groups of patients, regardless of the technique used for haemostasis. Conclusions: The use of continuous suctioning during adenoidectomy haemostasis significantly shortens total surgical and haemostasis time, reduces intraoperative blood loss, and reduces the incidence of haemostasis failure (with the consequent need for bipolar electrocautery haemostasis).

Efficacy and safety of the Arctic Sun device for hypoxic-ischemic encephalopathy in adult patients following cardiopulmonary resuscitation: A systematic review and meta-analysis

AIM

The principal objective of this study was to carry out a comprehensive and thorough analysis to compare the safety and effectiveness of the Arctic Sun, a servo-controlled surface cooling device, with conventional cooling techniques for providing therapeutic hypothermia in adult patients who had experienced hypoxic-ischemic brain injury following cardiopulmonary resuscitation.

METHODS

In order to achieve our goal, we conducted an extensive search of multiple databases including PubMed, Embase, Cochrane, and ClinicalTrials.gov up to the date of July 30, 2021. We only included studies that compared the safety and efficacy of the Arctic Sun surface cooling equipment with standard cooling approaches such as cooling blankets, ice packs, and intravenous cold saline for treating comatose adult patients who had recovered after experiencing cardiac arrest. We evaluated various outcomes, including all-cause mortality, good neurological outcome at 1 month, and the occurrence of adverse effects such as infections, shock, and bleeding. We employed a random-effects meta-analysis to estimate the odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes.

RESULTS

One hundred and fourteen records were identified through our search; however, only three studies met our eligibility criteria, resulting in overall 187 patients incorporated in the meta-analysis. The findings indicated no significant difference in mortality rates among the Arctic Sun device and conventional cooling techniques (OR: 0.64; 95% CI: 0.34-1.19; P = 0.16; I2 = 0%). In addition, we found no significant difference in occurrence of good neurological outcomes (OR: 1.74; 95% CI: 0.94-3.25; P = 0.08; I2 = 0%) between the two cooling methods. However, the application of the Arctic Sun device was associated with increased incidence of infections compared to standard cooling methods (OR: 2.46; 95% CI: 1.18-5.11; P = 0.02; I2 = 0%). While no significant difference occurred in the incidence of shock (OR: 0.29; 95% CI: 0.07-1.18; P = 0.08; I2 = 40%), the use of the Arctic Sun device was linked to significantly fewer bleeding complications compared to standard cooling methods (OR: 0.11; 95% CI: 0.02-0.79; P = 0.03; I2 = 0%).

CONCLUSIONS

After analyzing the results of our meta-analysis, we concluded that the use of the Arctic Sun device for targeted temperature management following cardiopulmonary resuscitation did not result in significant differences in mortality rates or improve neurological outcomes when compared to standard cooling techniques.

Hypothermia may reduce mortality and improve neurologic outcomes in adult patients treated with VA-ECMO: A systematic review and meta-analysis

BACKGROUND

VA-ECMO can greatly reduce mortality in critically ill patients, and hypothermia attenuates the deleterious effects of ischemia-reperfusion injury. We aimed to study the effects of hypothermia on mortality and neurological outcomes in VA-ECMO patients.

METHODS

A systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases was performed from the earliest available date to 31 December 2022. The primary outcome was discharge or 28-day mortality and favorable neurological outcomes in VA-ECMO patients, and the secondary outcome was bleeding risk in VA-ECMO patients. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Based on the heterogeneity assessed by the I² statistic, meta-analyses were performed using random or fixed-effects models. GRADE methodology was used to rate the certainty in the findings.

RESULTS

A total of 27 articles (3782 patients) were included. Hypothermia (33-35 °C) lasting at least 24 h can significantly reduce discharge or 28-day mortality (OR, 0.45; 95% CI, 0.33-0.63; I² = 41%) and significantly improve favorable neurological outcomes (OR, 2.08; 95% CI, 1.66-2.61; I² = 3%) in VA-ECMO patients. Additionally, there was no risk associated with bleeding (OR, 1.15; 95% CI, 0.86-1.53; I² = 12%). In our subgroup analysis according to in-hospital or out-of-hospital cardiac arrest, hypothermia reduced short-term mortality in both VA-ECMO-assisted in-hospital (OR, 0.30; 95% CI, 0.11-0.86; I² = 0.0%) and out-of-hospital cardiac arrest (OR, 0.41; 95% CI, 0.25-0.69; I² = 52.3%). Out-of-hospital cardiac arrest patients assisted by VA-ECMO for favorable neurological outcomes were consistent with the conclusions of this paper (OR, 2.10; 95% CI, 1.63-2.72; I² = 0.5%).

CONCLUSIONS

Our results show that mild hypothermia (33-35 °C) lasting at least 24 h can greatly reduce short-term mortality and significantly improve favorable short-term neurologic outcomes in VA-ECMO-assisted patients without bleeding-related risks. As the grade assessment indicated that the certainty of the evidence was relatively low, hypothermia as a strategy for VA-ECMO-assisted patient care may need to be treated with caution.

Mild induced hypothermia and coagulation and platelet function in patients with septic shock: Secondary outcome of a randomized trial

Coagulation abnormalities and microthrombi contribute to septic shock, but the impact of body temperature regulation on coagulation in patients with sepsis is unknown. We tested the hypothesis that mild induced hypothermia reduces coagulation and platelet aggregation in patients with septic shock. Secondary analysis of randomized controlled trial. Adult patients with septic shock who required mechanical ventilation from eight intensive care units in Denmark were randomly assigned to mild induced hypothermia for 24 h or routine thermal management. Viscoelastography and platelet aggregation were assessed at trial inclusion, after 12 h of thermal management, and 24 h after inclusion. A total of 326 patients were randomized to mild induced hypothermia (n = 163) or routine thermal management (n = 163). Mild induced hypothermia slightly prolonged activated partial thromboplastin time and thrombus initiation time (R time 8.0 min [interquartile range, IQR 6.6-11.1] vs. 7.2 min [IQR 5.8-9.2]; p = .004) and marginally inhibited thrombus propagation (angle 68° [IQR 59-73] vs. 71° [IQR 63-75]; p = .014). The effect was also present after 24 h. Clot strength remained unaffected (MA 71 mm [IQR 66-76] with mild induced hypothermia vs. 72 mm (65-77) with routine thermal management, p = .9). The proportion of patients with hyperfibrinolysis was not affected (0.7% vs. 3.3%; p = .19), but the proportion of patients with no fibrinolysis was high in the mild hypothermia group (8.8% vs. 40.4%; p < .001). The mild induced hypothermia group had lower platelet aggregation: ASPI 85U (IQR 50-113) versus 109U (IQR 74-148, p < .001), ADP 61U (IQR 40-83) versus 79 U (IQR 54-101, p < .001), TRAP 108 (IQR 83-154) versus 119 (IQR 94-146, p = .042) and COL 50U (IQR 34-66) versus 67U (IQR 46-92, p < .001). In patients with septic shock, mild induced hypothermia slightly impaired clot initiation, but did not change clot strength. Platelet aggregation was slightly impaired. The effect of mild induced hypothermia on viscoelastography and platelet aggregation was however not in a range that would have clinical implications. We did observe a substantial reduction in fibrinolysis.

Incidence and predictors of mortality among adult trauma patients admitted to the intensive care units of comprehensive specialized hospitals in Northwest Ethiopia

BACKGROUND

Trauma is the leading cause of morbidity and mortality among adult population in the world. Despite many improvements in technology and care, mortality among trauma patients in the intensive care unit is still high particularly in Ethiopia. However, there is limited evidence on the incidence and predictors of mortality among trauma patients in Ethiopia. Therefore, this study aimed to assess the incidence and predictors of mortality among adult trauma patients admitted to intensive care units.

METHODS

Institutional-based retrospective follow-up study was conducted from January 9, 2019 to January 8, 2022. A total of 421 samples were chosen using simple random sampling. Data were collected with Kobo toolbox software and exported to STATA version 14.1 software for data analysis. Kaplan-Meier failure curve and log-rank test were fitted to explore the survival difference among groups. After the bivariable and multivariable Cox regression analysis, an Adjusted Hazard Ratio (AHR) with 95% Confidence Intervals (CI) was reported to declare the strength of association and statistical significance, respectively.

RESULT

The overall incidence rate of mortality was 5.47 per 100 person-day observation with a median survival time of 14 days. Did not get pre-hospital care (AHR = 2.00, 95%CI 1.13, 3.53), Glasgow Coma Scale (GCS) score < 9 (AHR = 3.89, 95%CI 1.67, 9.06), presence of complications (AHR = 3.71, 95%CI 1.29, 10.64), hypothermia at admission (AHR = 2.11, 95%CI 1.13, 3.93) and hypotension at admission (AHR = 1.93, 95%CI 1.01, 3.66) were found significant predictors of mortality among trauma patients.

CONCLUSION

The incidence rate of mortality among trauma patients in the ICU was high. Did not get pre-hospital care, GCS < 9, presence of complications, hypothermia, and hypotension at admission were significant predictors of mortality. Therefore, healthcare providers should give special attention to trauma patients with low GCS scores, complications, hypotension, and hypothermia and better to strengthen pre-hospital services to reduce the incidence of mortality.

A Nomogram for Predicting Unplanned Intraoperative Hypothermia in Patients With Colorectal Cancer Undergoing Laparoscopic Colorectal Procedures

Unplanned intraoperative hypothermia is a complication that can lead to a variety of negative outcomes, such as cardiovascular events. We aimed to develop and validate an intraoperative hypothermia risk prediction nomogram for patients with colorectal cancer undergoing laparoscopic colorectal procedures. We conducted a prospective cohort study with 1,091 patients (ie, 765 in the training cohort, 326 in the validation cohort) from October 2020 to November 2021. We included six predictors in the nomogram model: body mass index, diabetes diagnosis, ambient temperature, ambient humidity, duration of surgery, and use of a forced-air warmer. The model performed well, and the area under the curve was 0.855. These results, together with an external validation value, mean that health care professionals can use the nomogram to calculate the intraoperative hypothermia risk for patients undergoing laparoscopic colorectal procedures and make clinical decisions based on the results.

PEG-mediated hybrid hemostatic gauze with in-situ growth and tightly-bound mesoporous silicon

Pre-hospital control of bleeding is critical to save lives, however the development of hemostatic agents with efficient and safe performance is still a challenge. In this study, a hybrid hemostatic gauze (MG-PEG) with in-situ growth and tightly bound mesoporous silicon (MSN) was prepared by template method for hemorrhage control. This material integrated meso-porosity, blood coagulation and stability into flexible gauze fiber. The PEG in MG-PEG was not only used as template for the in-suit MSN growth, but also acted as joint connection between the gauze fibers and MSN. The MSN particles were firmly bound to the surface of gauze fibers with extremely low leakage after 3 min of sonication and displayed a comparable coagulant activity to untreated sample. The results of animal experiments confirmed that MG-PEG possessed superior hemostatic performance over silicates-based inorganic hemostasis-Combat Gauze, in terms of higher coagulant activity (in vivo clotting time <200 s), minimized loss of active components (liquids OD was only 3 % of CG), well biocompatibility (hemolysis ratio < 5 %, no cytotoxicity) and wider indications range for practical application.

Accidental hypothermia: pathophysiology, investigations and management

Accidental hypothermia, defined as an unintentional decrease in core body temperature to below 35°C, adversely affects several body systems, including the cardiovascular, central nervous and renal systems. It is classified according to core body temperature from a maximum of 35°C in mild hypothermia to below 24°C in profound hypothermia. Patients with severe hypothermia (28°C-24°C) are at risk of cardiac arrythmias and cardiac arrest. In patients presenting with hypothermia, it is vital to prevent any further heat loss and quickly start rewarming them. Nurses working in the emergency department have a crucial role in supporting the optimal recovery of hypothermic patients. This article explains the pathophysiology of hypothermia, describes the investigations conducted in patients with accidental hypothermia and discusses management and nursing care.

Nursing Care during the Perioperative within the Surgical Context

The study describes basic nursing care during the perioperative. Introduces the origins of perioperative nursing, general care that must be practiced with patient in this context. During the preoperative, care related with risk assessment and preparation of patient from the emotional and physical point of view are important. The trans-operative is related with the anesthesia used, surgical position, preparation of the skin, maintenance of normothermia, among many others. The postoperative depends on the type of anesthesia and surgical procedure, emphasizing on airway permeability, hemodynamic stability, pain, and symptomatology being presented by patients until they are stable and suitable for transfer to another service or their home.

N-Acetyl-L-Cysteine Protects Organ Function After Hemorrhagic Shock Combined With Seawater Immersion in Rats by Correcting Coagulopathy and Acidosis

Background

The mortality of trauma combined with seawater immersion is higher than that of land injury, however, research on how to treat this critical case and which treatments to adopt is lacking.

Methods

The effect of the thiol compound, N-acetyl-L-Cysteine (NAC), on survival, acidosis, coagulopathy, vital signs, oxidative stress, and mitochondrial and multi-organ function was assessed in a rat model of hemorrhagic shock combined with seawater immersion (Sea-Shock).

Results

Hemorrhagic shock combined with seawater immersion caused a severe lethal triad: multi-organ impairment, oxidative stress, and mitochondrial dysfunction. NAC (30 mg/kg) with lactated Ringer’s (LR) solution (2 × blood volume lost) significantly improved outcomes compared to LR or hetastarch (HES 130/0.4) alone. NAC significantly prolonged survival time to 52.48 ± 30.09 h and increased 72 h survival rate to 11/16 (68%). NAC relieved metabolic acidosis and recovered the pH back to 7.33. NAC also restored coagulation, with APTT, PT, and PT-INR decreased by 109.31, 78.09, and 73.74%, respectively, while fibrinogen level increased 246.23% compared with untreated Sea-Shock. Administration of NAC markedly improved cardiac and liver function, with some improvement of kidney function.

Conclusion

The addition of NAC to crystalloid resuscitation fluid alleviated oxidative stress, restored redox homeostasis, and provided multi-organ protection in the rats after Sea-Shock. NAC may be an effective therapeutic measure for hemorrhagic shock combined with seawater immersion.

Physiological Changes in Subjects Exposed to Accidental Hypothermia: An Update

Background

Accidental hypothermia (AH) is an unintended decrease in body core temperature (BCT) to below 35°C. We present an update on physiological/pathophysiological changes associated with AH and rewarming from hypothermic cardiac arrest (HCA).

Temperature Regulation and Metabolism

Triggered by falling skin temperature, Thyrotropin-Releasing Hormone (TRH) from hypothalamus induces release of Thyroid-Stimulating Hormone (TSH) and Prolactin from pituitary gland anterior lobe that stimulate thyroid generation of triiodothyronine and thyroxine (T4). The latter act together with noradrenaline to induce heat production by binding to adrenergic β3-receptors in fat cells. Exposed to cold, noradrenaline prompts degradation of triglycerides from brown adipose tissue (BAT) into free fatty acids that uncouple metabolism to heat production, rather than generating adenosine triphosphate. If BAT is lacking, AH occurs more readily.

Cardiac Output

Assuming a 7% drop in metabolism per °C, a BCT decrease of 10°C can reduce metabolism by 70% paralleled by a corresponding decline in CO. Consequently, it is possible to maintain adequate oxygen delivery provided correctly performed cardiopulmonary resuscitation (CPR), which might result in approximately 30% of CO generated at normal BCT.

Liver and Coagulation

AH promotes coagulation disturbances following trauma and acidosis by reducing coagulation and platelet functions. Mean prothrombin and partial thromboplastin times might increase by 40–60% in moderate hypothermia. Rewarming might release tissue factor from damaged tissues, that triggers disseminated intravascular coagulation. Hypothermia might inhibit platelet aggregation and coagulation.

Kidneys

Renal blood flow decreases due to vasoconstriction of afferent arterioles, electrolyte and fluid disturbances and increasing blood viscosity. Severely deranged renal function occurs particularly in the presence of rhabdomyolysis induced by severe AH combined with trauma.

Conclusion

Metabolism drops 7% per °C fall in BCT, reducing CO correspondingly. Therefore, it is possible to maintain adequate oxygen delivery after 10°C drop in BCT provided correctly performed CPR. Hypothermia may facilitate rhabdomyolysis in traumatized patients. Victims suspected of HCA should be rewarmed before being pronounced dead. Rewarming avalanche victims of HCA with serum potassium > 12 mmol/L and a burial time >30 min with no air pocket, most probably be futile.

Accidental Hypothermia: 2021 Update

Accidental hypothermia is an unintentional drop of core temperature below 35 °C. Annually, thousands die of primary hypothermia and an unknown number die of secondary hypothermia worldwide. Hypothermia can be expected in emergency patients in the prehospital phase. Injured and intoxicated patients cool quickly even in subtropical regions. Preventive measures are important to avoid hypothermia or cooling in ill or injured patients. Diagnosis and assessment of the risk of cardiac arrest are based on clinical signs and core temperature measurement when available. Hypothermic patients with risk factors for imminent cardiac arrest (temperature < 30 °C in young and healthy patients and <32 °C in elderly persons, or patients with multiple comorbidities), ventricular dysrhythmias, or systolic blood pressure < 90 mmHg) and hypothermic patients who are already in cardiac arrest, should be transferred directly to an extracorporeal life support (ECLS) centre. If a hypothermic patient arrests, continuous cardiopulmonary resuscitation (CPR) should be performed. In hypothermic patients, the chances of survival and good neurological outcome are higher than for normothermic patients for witnessed, unwitnessed and asystolic cardiac arrest. Mechanical CPR devices should be used for prolonged rescue, if available. In severely hypothermic patients in cardiac arrest, if continuous or mechanical CPR is not possible, intermittent CPR should be used. Rewarming can be accomplished by passive and active techniques. Most often, passive and active external techniques are used. Only in patients with refractory hypothermia or cardiac arrest are internal rewarming techniques required. ECLS rewarming should be performed with extracorporeal membrane oxygenation (ECMO). A post-resuscitation care bundle should complement treatment.

Effectiveness of Combined Strategies for the Prevention of Hypothermia Measured by Noninvasive Zero-Heat Flux Thermometer During Cesarean Section

Background: Perioperative hypothermia (body temperature <36°C) is a common complication of anesthesia increasing the risk for maternal cardiovascular events and coagulative disorders, and can also influence neonatal health. The aim of our work was to evaluate the impact of combined warming strategies on maternal core temperature, measured with the SpotOn. We hypothesized that combined modalities of active warming prevent hypothermia in pregnant women undergoing cesarean delivery with spinal anesthesia. Methods: Seventy-eight pregnant women were randomly allocated into three study groups receiving warmed IV fluids and forced-air warming (AW), warmed IV fluids (WF), or no warming (NW). Noninvasive core temperature device (SpotOn) measured maternal core temperature intraoperatively and for 30 min after surgery. Maternal mean arterial pressure, incidence of shivering, thermal comfort and newborn's APGAR, axillary temperature, weight, and blood gas analysis were also recorded. Results: Incidence of hypothermia was of 0% in AW, 4% in WF, and 47% in NW. Core temperature in AW was constantly higher than WF and NW groups. Incidence of shivering in perioperative time was significantly lower in AW and WF groups compared with the NW group (p < 0.04). Thermal comfort was higher in both AW and WF groups compared with NW group (p = 0.02 and p = 0.008, respectively). There were no significant differences among groups for the other evaluated parameters. Conclusion: Combined modalities of active warming are effective in preventing perioperative hypothermia. The routine uses of combined AW are suggested in the setting of cesarean delivery.

Risk Prediction Models for Inadvertent Intraoperative Hypothermia: A Systematic Review

PURPOSES

Inadvertent intraoperative hypothermia (core temperature <36°C) is a common surgical complication with several adverse events. Hypothermia prediction models can be a tool for providing the healthcare staff with information on the risk of inadvertent hypothermia. Our systematic review aimed to identify, demonstrate, and evaluate the available intraoperative hypothermia risk prediction models in surgical populations.

DESIGN

This study is a systematic review of literature.

METHODS

We systematically searched multiple databases (Ovid MEDLINE, Web of Science, Embase, and Cochrane Center Register of Controlled Trials). Two reviewers independently examined abstracts and the full text for eligibility. Data collection was guided by the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS checklist), and methodological quality and applicability were assessed by the Prediction model Risk Of Bias ASsessment Tool (PROBAST).

FINDINGS

A total of 3,672 references were screened, of which eight articles were included in this study. All the models had a high risk of bias since most of them lacked model validation. Also, they failed to report the model performance and final model presentations, which restricted their clinical application.

CONCLUSIONS

The researchers should present models in a more standard way and improve the existing models to increase their predictive values for clinical application.

Effects of Changes in Body Temperature on Perioperative Bleeding in Adolescent Idiopathic Scoliosis Surgery

Perioperative bleeding is a critical challenge in adolescent idiopathic scoliosis (AIS) surgery. Preventing hypothermia is associated with decreased development of coagulopathy, blood transfusion rate in various surgery groups. We hypothesized that blood loss would be reduced in patients who were kept normothermic by implementation of aggressive warming methods in AIS. This randomized-controlled study included patients aged 12-18 years who were scheduled to undergo elective scoliosis deformity correction surgery. The patients were divided into two groups: the study group (Group S) was heated aggressively with three different heaters including compressed-air blower heater, intravenous fluid heating, and a heating bed, while the control group (Group C) received only heating with a standard compressed-air blower heater. Tympanic, esophageal, and axillary body temperatures were measured, and hemoglobin and arterial blood gas analyses were repeated during the anesthesia period. Daily bleeding-coagulation parameters were recorded on postoperative days 0, 1, and 2. Forty-eight patients were randomized, and 39 patients were included into the final analysis. The total amount of intraoperative bleeding (p = 0.027) was significantly lower, and duration of surgery (p = 0.025) and length of hospital stay (p = 0.002) were significantly shorter in Group S. Significant linear relationships were found between the core body temperature and the amount of bleeding (β = 0.0001; p = 0.009), operation time (β = 0.003; p = 0.015), and length of hospital stay (β = 0.027; p = 0.044) with linear logistic regression analysis. We reported that normothermia was preserved in the multiheated group, which diminished blood loss, operation time, and the length of hospital stay. Consequently, we suggested that active heating should be applied in AIS surgeries. ClinicalTrials.gov (NCT04686214).

Thrombin immobilized polydopamine-diatom biosilica for effective hemorrhage control

In this study, an efficient composite hemostatic material (DA-diatom-T) was prepared, using a polydopamine layer as a linker to immobilize thrombin on the surface of diatom biosilica. DA-diatom-T retained the porous structure of the diatom with high water absorption capacity, which can absorb 31 times its own weight of water. The thrombin activity of DA-diatom-T was as high as 5.81 U mg-1 that could be maintained at 67% after 30 days at room temperature. DA-diatom-T exhibited non-toxicity to mouse fibroblast cell lines, favorable hemocompatibility and fast procoagulant ability. DA-diatom-T could promote the initiation of the coagulation process and increase platelet activity and blood clot strength to form a physical barrier at the wound. In an in vivo study, DA-diatom-T could significantly reduce the clotting time and reduce the bleeding volume. The above results showed that DA-diatom-T had potential as a new hemostatic material.

Ticagrelor effectively inhibits platelet aggregation in comatose survivors of cardiac arrest undergoing primary percutaneous coronary intervention treated with mild therapeutic hypothermia

BACKGROUND

Mild therapeutic hypothermia (MTH) is believed to reduce the effectiveness of antiplatelet drugs. Effective dual-antiplatelet therapy after percutaneous coronary intervention (PCI) is mandatory to avoid acute stent thrombosis. The effectiveness of ticagrelor in MTH-treated out-of-hospital cardiac arrest (OHCA) survivors is still a matter of debate. The aim of the study was to evaluate the impact of MTH on the platelet-inhibitory effect of ticagrelor in comatose survivors of OHCA treated with primary PCI.

METHODS

Eighteen comatose survivors of OHCA with acute coronary syndrome undergoing immediate PCI treated with MTH were compared with 14 patients with uncomplicated primary myocardial infarction after PCI, matched for gender and age, in a prospective, single-center, observational study. Platelet aggregation was evaluated using VerifyNow P₂Y₁₂ point-of-care testing at 3 time points: admission (T₀), during MTH (T₁), and 48-72 h after rewarming (T₂).

RESULTS

Ticagrelor effectively inhibits platelet aggregation in OHCA patients subjected to MTH and in all patients in the control group. The effectiveness of ticagrelor did not differ between the MTH group and the control group (p = 0.581). In 2 cases in the MTH population, the platelet response to ticagrelor was inadequate, and in one of them it remained insufficient during the re-warming phase. There was no stent thrombosis in these patients.

CONCLUSIONS

The present study confirmed the effectiveness of ticagrelor to inhibit platelets in myocardial infarction patients after OHCA treated with primary PCI undergoing hypothermia. The use of cooling was not associated with an increased risk of stent thrombosis.

Effects of Systemic Hypothermia on Microcirculation in Conditions of Hemodynamic Stability and in Hemorrhagic Shock

INTRODUCTION

Although hypothermia is independently associated with an increased mortality in trauma patients, it might be an effective therapeutic approach for otherwise lethal hemorrhage. The effect of hypothermia on microcirculation, however, has been poorly studied in this setting. Our goal was to characterize the effects of hypothermia on microcirculation in normal conditions and in severe hemorrhagic shock.

METHODS

In anesthetized and mechanically ventilated sheep, we measured cardiac output (CO), renal blood flow (RBF), and systemic and renal O2 consumption (VO2). Cortical renal, intestinal villi, and sublingual microcirculation was assessed by IDF-videomicroscopy. After basal measurements, sheep were assigned to hypothermia (n = 12) and normothermia (n = 12) groups. Central temperature was reduced to ∼34°C and maintained at baseline in each group, respectively. Measurements were repeated after 1 h of hemodynamic stable conditions and 1 h of severe hemorrhagic shock.

RESULTS

In conditions of hemodynamic stability, the hypothermia group showed lower CO, RBF, and systemic and renal VO2 than the normothermia group. Red blood cell velocity was also lower in renal, villi, and sublingual microvascular beds (836 ± 195 vs. 1,066 ± 162, 916 ± 105 vs. 1051 ± 41, and 970 ± 182 vs. 1,102 ± 49 μm/s, respectively; P < 0.0001 for all). In hemorrhagic shock, most of the microvascular variables were similarly compromised in both the groups. In hypo- and normothermia groups, the percentage of reduction in perfused vascular density was higher in renal than in intestinal and sublingual microcirculation (66 ± 31 vs. 31 ± 23 and 15 ± 15%, and 78 ± 26 vs. 32 ± 37 and 18 ± 21%, P < 0.01 for both).

CONCLUSIONS

This is the first experimental study assessing the effect of systemic hypothermia on microcirculation in severe hemorrhagic shock. The main finding was that hypothermia did not hamper additionally the microcirculatory derangements induced by hemorrhagic shock. In addition, renal microcirculation was more susceptible to hemorrhagic shock than villi and sublingual microcirculation.

A survey of patient blood management for patients undergoing cardiac surgery in nine European countries

STUDY OBJECTIVE

To describe and compare patient blood management (PBM) practices in cardiac surgery in nine European countries and identify the main risk factors for bleeding or transfusion according to the surveyed centres.

DESIGN

We set up an online survey to evaluate PBM practices in two clinical scenarios, risk factors for bleeding or transfusion, and previous experience with antifibrinolytics.

SETTING

This survey was completed by European anesthesiologists in 2019.

PATIENTS

No patients were included in the survey.

INTERVENTION

None.

MEASUREMENTS

We evaluated the degree of implementation of PBM practices in patients undergoing cardiac surgery.

MAIN RESULTS

Ninety-eight of 177 responses (38%) were complete with variable response rates by country. In a non-emergent situation, no respondents would transfuse red cells preoperatively in an anaemic patient, while cell salvage (89%) and antifibrinolytics (82%) would almost always be used. Optimization of Hemoglobin level (36%) and use of off-pump techniques (34%), minimally invasive surgery (25%) and relatively recently-developed CPB technologies such as mini-bypass (32%) and autologous priming (38%), varied greatly across countries. In an emergent clinical situation, topical haemostatic agents would frequently be used (61%). Tranexamic acid (72%) and aprotinin (20%) were the main antifibrinolytics used, with method of administration and dose varying markedly across countries. Five factors were considered to increase risk of bleeding or transfusion by at least 90% of respondents: pre-operative anaemia, prior cardiac surgery, clopidogrel 5 days or less before surgery, use of other P2Y12 inhibitors at any point, and thrombocytopenia <100.10⁹ platelets/mm³.

CONCLUSION

PBM guidelines are not universally implemented in European cardiac surgery centres or countries, resulting in discrepancies in techniques and products used for a given clinical situation.

Short-Periods of Pre-Warming in Laparoscopic Surgery. A Non-Randomized Clinical Trial Evaluating Current Clinical Practice

Background: Pre-warming prevents perioperative hypothermia. We evaluated the current clinical practice of pre-warming and its effects on temperature drop and postoperative complications; Methods: This prospective, observational pilot study examines clinical practice in a tertiary hospital on 99 patients undergoing laparoscopic urological surgery. Pre-warming was performed in the pre-anesthesia room. Patients were classified into three groups: P 0 (non-prewarmed), P 5–15 (pre-warming 5–15 min) and P > 15 (pre-warming 15–30 min). Tympanic temperature was recorded in the pre-anesthesia room, prior to anesthesia induction, and in the PACU. Esophageal temperature was recorded intraoperatively. The occurrence of shivering, pain intensity, length of stay in PACU, and postoperative complications during hospital stay were also recorded; Results: After pre-warming, between-group difference in body temperature was higher in P > 15 than in P 0 (0.4 °C, 95% CI 0.14–0.69, p = 0.004). Between P 5–15 and P 0 difference was 0.2 °C (95% CI 0.04–0.55, p = 0.093). Temperature at the end of surgery was higher in pre-warmed groups [mean between-group difference 0.5 °C (95% CI 0.13–0.81, p = 0.007) for P 5–15; 0.9 °C (95% CI 0.55–1.19, p < 0.001) for P > 15]. Pain and shivering was less common in pre-warmed groups. Postoperative transfusions and surgical site infections were lower in P > 15; Conclusion: Short-term pre-warming prior to laparoscopic urological surgery decreased temperature perioperative drop and postoperative complications.

Postoperative hypothermia after total aortic arch replacement in acute type A aortic dissection-multivariate analysis and risk identification for postoperative hypothermia occurrence

Background

Postoperative hypothermia (PH) is a common physiological abnormality associated with increased morbidity and mortality after non-cardiac surgery. The incidence, risk factors of PH and its impact on early outcomes after total aortic arch replacement are not clear.

Methods

We conducted a retrospective cohort study in patients with acute type A aortic dissection who underwent total arch replacement from January 2013 to December 2016 at our institution. Basic variables, procedural and postoperative early outcomes were collected. Univariate and multivariate statistical analysis were performed for statistical interpretation. The early outcomes were compared between patients with or without PH.

Results

A total of 300 patients (age 53.8±11.5 years, female 63, 21.0%) with acute type A aortic dissection underwent total arch replacement. Forty-four patients (14.7%) developed PH. The independent risk factors of PH are age and the intraoperative lowest bladder temperature. There is no significant difference in major postoperative morbidity and mortality between patients with or without PH.

Conclusions

The incidence of PH after total arch replacement in acute type A aortic dissection is relatively low. The independent risk factors of PH in this population include age and the intraoperative lowest bladder temperature. With comprehensive rewarming strategy upon arrival at the ICU, the PH is easy to be corrected, and the adverse effect of transient PH on early outcomes after arch surgery is minimal.

Platelet Dysfunction Diseases and Conditions: Clinical Implications and Considerations

INTRODUCTION

Platelet diseases and dysfunction are taught early in medical school to all future physicians. Understanding of the coagulation cascade and hemostatic mechanisms has allowed for targeted pharmacological therapies that have been significantly impactful in clinical practice. Platelets are an early participant in hemostasis physiologically and under pathophysiological states.

METHODS

A review of literature involving platelet disfunction.

RESULTS

Various presentations of platelet diseases and dysfunction challenge clinicians and require a firm understanding of normal platelet function, drugs that mediate or modulate platelet effectiveness, and nonpharmacologic etiologies of platelet diseases and dysfunction with corresponding best practice treatment approaches.

CONCLUSION

This review summarizes normal and abnormal states associated with platelets and treatment strategies.