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Ambient operating room temperature: Mother, baby or surgeon?

DOI:10.1093/bja/aex307
Authors:
Pervez Sultan at Stanford University School of Medicine
Pervez Sultan
  • Stanford University School of Medicine
Ashraf Habib at Duke University Medical Center
Ashraf Habib
Brendan Carvalho at Stanford University
Brendan Carvalho
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Abstract

Editor-We thank Siedentopf 1 for raising an important point regarding ambient operating theatre temperature and its potential influence upon maternal and neonatal hypothermia during and after Caesarean delivery. The World Health Organization (WHO) recommends a delivery room temperature of 25-28 C to reduce the incidence of neonatal hypothermia. 2 These guidelines do not, however, specifically recommend ideal operating theatre ambient temperatures nor the optimal temperature required to prevent maternal hypothermia. A recently published study by Duryea and colleagues 3 specifically explored the impact of operating theatre temperature on maternal and neonatal outcomes. The authors performed a cluster randomization schedule to either 20 C (standard operating room ambient temperature) or 23 C (maximum ambient temperature allowed by hospital policy). Results from 791 mothers (and 825 neonates) undergoing elective or emergency Caesarean delivery under either regional or general anaesthesia demonstrated a significantly lower incidence of mild (<36.5 C) and moderate-to-severe neonatal hypothermia (<36 C) when ambient operating theatre temperature was 23 C, with con-comitant use of warmed fluids in all parturients. Although neona-tal morbidity did not differ between groups, the study was not powered to detect such differences. Maternal hypothermia on arrival to the postoperative care area was only modestly reduced with increased operating theatre temperature (36.1 6 0.6 C vs 36.2 6 0.6 C) with no clinical differences between groups. In the randomized controlled studies included in our published meta-analysis, two studies did not record ambient temperature (Chung, Jorgensen); the remaining studies reported ambient temperatures between 20 C and 25 C, with the majority of studies (Butwick, Chan, Fallis, Goyal, Horn 2002, Horn 2014, Paris, Smith) reporting ambient temperatures between 21 C and 24 C. 4 Of note, ambient temperatures did not significantly differ between warmed and control groups within each of these studies. The lower operating theatre temperatures utilized in these studies (compared with the WHO recommended delivery room temperature) are likely to be according to local practices to maintain staff comfort. Intraoperative comfort of the surgical team is an important factor when considering increasing ambient temperatures within the operating theatre. Of surgeons surveyed by Duryea and colleagues , 3 56% described discomfort at 23 C, with 21% also reporting that higher ambient temperatures affected their performance, 3 while 93% of surgeons did state that they would tolerate higher ambient temperatures if it had a positive impact upon neonatal outcomes. Although the optimal delivery room temperature is recommended to be 25-28 C, the reality is that this temperature range is unlikely to be tolerated by operating room staff. Our meta-analysis demonstrates that active warming using forced air warming and/or fluid warming is a simple intervention that can reduce maternal hypothermia. Neonatal warming strategies (such as radiant warmer, drying towels, skin-to-skin and forced air-skin-surface warming) are important to help reduce the incidence of neonatal hypothermia in the operating theatre environment. Declaration of interest None declared. References 1. Siedentopf JP. Does surrounding temperature influence the rate of hypothermia during Caesarean section? Br J Anaesth 2017; 119: 838 2. World Health Organization (WHO). Thermal control of the newborn: a practical guide. In: Maternal Health and Safe Motherhood Programme (WHO/FHE/MSM/93.2). Geneva: WHO, 1996 3. Duryea EL, Nelson DB, Wyckoff MH, et al. The impact of ambient operating room temperature on neonatal and maternal hypo-thermia and associated morbidities: a randomized controlled trial. Am J Obstet Gynecol 2016; 214: 505.e1-7 4. Sultan P, Habib AS, Cho Y, Carvalho B. The Effect of patient warming during Caesarean delivery on maternal and neona-tal outcomes: a meta-analysis. Br
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Ambient operating room temperature: mother, baby or surgeon?
P. Sultan
1,
*, A. S. Habib
2
, and B. Carvalho
3
1
Department of Anaesthesia, University College London Hospital, London, UK,
2
Department of Anesthesia,
Duke University School of Medicine, Durham, NC, USA and
3
Department of Anesthesia, Stanford University
School of Medicine, Stanford, CA, USA
*E-mail: p.sultan@doctors.org.uk
Editor—We thank Siedentopf
1
for raising an important point
regarding ambient operating theatre temperature and its poten-
tial influence upon maternal and neonatal hypothermia during
and after Caesarean delivery. The World Health Organization
(WHO) recommends a delivery room temperature of 25–28 Cto
reduce the incidence of neonatal hypothermia.
2
These guidelines
do not, however, specifically recommend ideal operating theatre
ambient temperatures nor the optimal temperature required to
prevent maternal hypothermia. A recently published study by
Duryea and colleagues
3
specifically explored the impact of operat-
ing theatre temperature onmaternal and neonatal outcomes. The
authors performed a cluster randomization schedule to either
20C (standard operating room ambient temperature) or 23 C
(maximum ambient temperature allowed by hospital policy).
Results from 791 mothers (and 825 neonates) undergoing elective
or emergency Caesarean delivery under either regional or general
anaesthesia demonstrated a significantly lower incidence of mild
(<36.5 C) and moderate-to-severe neonatal hypothermia (<36C)
when ambient operating theatre temperature was 23 C, with con-
comitant use of warmed fluids in all parturients. Although neona-
tal morbidity did not differ between groups, the study was not
powered to detect such differences. Maternal hypothermia on
arrival to the postoperative care area was only modestly reduced
with increased operating theatre temperature (36.1 60.6 Cvs
36.2 60.6 C) with no clinical differences between groups.
In the randomized controlled studies included in our pub-
lished meta-analysis, two studies did not record ambient tem-
perature (Chung, Jorgensen); the remaining studies reported
ambient temperatures between 20C and 25 C, with the majority
of studies (Butwick, Chan, Fallis, Goyal, Horn 2002, Horn 2014,
Paris, Smith) reporting ambient temperatures between 21C and
24 C.
4
Of note, ambient temperatures did not significantly differ
between warmed and control groups within each of these stud-
ies. The lower operating theatre temperatures utilized in these
studies (compared with the WHO recommended delivery room
temperature) are likely to be according to local practices to main-
tain staff comfort.
Intraoperative comfort of the surgical team is an important fac-
tor when considering increasing ambient temperatures within the
operating theatre. Of surgeons surveyed by Duryea and col-
leagues,
3
56% described discomfort at 23C, with 21% also report-
ing that higher ambient temperatures affected their performance,
3
while 93% of surgeons did state that they would tolerate higher
ambient temperatures if it had a positive impact upon neonatal
outcomes. Although the optimal delivery room temperature is rec-
ommended to be 25–28 C, the reality is that this temperature
rangeisunlikelytobetoleratedby operating room staff. Our meta-
analysis demonstrates that active warming using forced air warm-
ing and/or fluid warming is a simple intervention that can reduce
maternal hypothermia. Neonatal warming strategies (such as radi-
ant warmer, drying towels, skin-to-skin and forced air–skin–sur-
face warming) are important to help reduce the incidence of
neonatal hypothermia in the operating theatre environment.
Declaration of interest
None declared.
References
1. Siedentopf JP. Does surrounding temperature influence the
rate of hypothermia during Caesarean section? Br J Anaesth
2017; 119: 838
2. World Health Organization (WHO). Thermal control of the
newborn: a practical guide. In: Maternal Health and Safe
Motherhood Programme (WHO/FHE/MSM/93.2). Geneva: WHO, 1996
3. Duryea EL, Nelson DB, Wyckoff MH, et al.Theimpactofambient
operating room temperature on neonatal and maternal hypo-
thermia and associated morbidities: a randomized controlled
trial. Am J Obstet Gynecol 2016; 214: 505.e1–7
4. Sultan P, Habib AS, Cho Y, Carvalho B. The Effect of patient
warming during Caesarean delivery on maternal and neona-
tal outcomes: a meta-analysis. Br J Anaesth 2015; 115: 500–10
doi: 10.1093/bja/aex307
Correspondence |839
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... On the other hand, this could be more realistic because most of the time the operating room temperature was around 21-22°C. Although the optimal delivery room temperature is recommended to be 25-28°C, it is also a fact that 25°C is an uncomfortable temperature for all operating room staff [20]. ...
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Surgery in neonatal, newborn and premature infants carries higher risk but the survival of premature, even extremely premature (<28 week gestation) and low (<1500 g) or extremely low birth weight (<1000 g) babies after surgery is on the rise due to the concerted efforts of technically skilled, experienced multidisciplinary team of neonatologist, surgeon, anaesthesiologist as well as nursing staff. Other factors contributing to their increased survival are availability of well-equipped ORs and NICUs with innovative and sophisticated gadgets which play a pivotal role in nursing the newborns preoperatively, not only in the developed world but also in developing countries, such as India. Babies are often born with various congenital anomalies involving major body systems with both anatomical and physiological implications, metabolic disorders, which makes them very much susceptible to developing complications, especially in the premature, such as respiratory distress syndrome, retinopathy of prematurity, intraventricular haemorrhage, and necrotising enterocolitis, that increase their morbidity and mortality. However, if diagnosed early at birth and treated accordingly, their survival improves. Though many critical surgeries are performed on neonates, much care is needed throughout the perioperative journey, to have a favourable outcome. General anesthesia is the preferred choice for most surgeries, but use of regional anaesthesia, use of noninvasive airway management greatly improves postoperative outcome. It must be kept in mind that premature babies are always at higher risk even after minor surgeries than healthy term neonates. A detailed preoperative evaluation, and optimization whenever possible, choice of anesthesia techniques and drugs, limiting preoperative nil per oral time (NPO), can greatly improve early recovery after anesthesia (ERAS) and help attain the outcome goals in the surgical neonate.
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Maternal and fetal hypothermia: more preventive compliance is required for a mother and her fetus while undergoing cesarean delivery; a quality improvement review
Article
Objective: Cesarean delivery is common, involves two patients, has numerous multi-disciplinary health care providers involved in the delivery management, but has variable levels of anesthesia and health services implementation for decreasing maternal hypothermia and the maternal and neonatal morbidity (and mortality). Limited implementation for either of the ERAS-CD or the ERAC guidelines, for inadvertent or preventive maternal hypothermia, is likely to be occurring on labor delivery floors. This Quality Improvement (QI) review focuses on cesarean delivery and maternal hypothermia. Methods: This quality and safety initiative used SQUIRE 2.0 methodology and concurrent PubMed searches to identify systematic review, meta-analysis, topic directed studies, additional published cohorts in the topic area not included in SR/MA, limited case reports that had specific clinical outcomes related to maternal hypothermia and fetal effects. Results: Two quality and safety improvement guidelines have defined the hypothermia activity element differently, with ERAS-CD recommending to prevent hypothermia, while ERAC recommending to maintain normothermia. The peer-reviewed literature indicates that the knowledge associated with surgical hypothermia outcome is known but it is not implemented for maternal cesarean delivery care. Increased maternal-effect recognition, surveillance, triage, and evidenced-based protocol management is required for the maternal - neonatal dyad undergoing cesarean delivery for the clinical reduction/prevention of neonatal hypothermia that has proven evidence-based maternal morbidity and neonatal morbidity/mortality. Conclusion: TEAM-based anesthesia, obstetrical, neonatology-pediatrics and nursing research collaboration is required through quality-safety-ERAS-ERAC directed processes. Healthcare system recognition and financial support is required for maternal-fetal-neonatal hypothermia prevention protocols implementation.
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The Effect of patient warming during Caesarean delivery on maternal and neonatal outcomes: A meta-analysis
Article
Full-text available
Background: Perioperative warming is recommended for surgery under anaesthesia, however its role during Caesarean delivery remains unclear. This meta-analysis aimed to determine the efficacy of active warming on outcomes after elective Caesarean delivery. Methods: We searched databases for randomized controlled trials utilizing forced air warming or warmed fluid within 30 min of neuraxial anaesthesia placement. Primary outcome was maximum temperature change. Secondary outcomes included maternal (end of surgery temperature, shivering, thermal comfort, hypothermia) and neonatal (temperature, umbilical cord pH and Apgar scores) outcomes. Standardized mean difference/mean difference/risk ratio (SMD/MD/RR) and 95% confidence interval (CI) were calculated using random effects modelling (CMA, version 2, 2005). Results: 13 studies met our criteria and 789 patients (416 warmed and 373 controls) were analysed for the primary outcome. Warming reduced temperature change (SMD -1.27°C [-1.86, -0.69]; P=0.00002); resulted in higher end of surgery temperatures (MD 0.43 °C [0.27, 0.59]; P<0.00001); was associated with less shivering (RR 0.58 [0.43, 0.79]; P=0.0004); improved thermal comfort (SMD 0.90 [0.36, 1.45]; P=0.001), and decreased hypothermia (RR 0.66 [0.50, 0.87]; P=0.003). Umbilical artery pH was higher in the warmed group (MD 0.02 [0, 0.05]; P=0.04). Egger's test (P=0.001) and contour-enhanced funnel plot suggest a risk of publication bias for the primary outcome of temperature change. Conclusions: Active warming for elective Caesarean delivery decreases perioperative temperature reduction and the incidence of hypothermia and shivering. These findings suggest that forced air warming or warmed fluid should be used for elective Caesarean delivery.
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The Impact of Ambient Operating Room Temperature on Neonatal and Maternal Hypothermia and Associated Morbidities: A Randomized Controlled Trial
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Background: Neonatal hypothermia is common at the time of cesarean delivery and has been associated with a constellation of morbidities in addition to increased neonatal mortality. Additionally, maternal hypothermia is often uncomfortable for the surgical patient and has been associated with intraoperative and postoperative complications. Various methods to decrease the rates of neonatal and maternal hypothermia have been examined and found to have varying levels of success. Objective: To determine whether an increase in operating room temperature at cesarean delivery results in a decrease in the rate of neonatal hypothermia and associated morbidities. Study design: In this single-center randomized trial, operating room temperatures were adjusted weekly according to a cluster randomization schedule to either 20°C (67°F) which was the standard at our institution or 23°C (73°F) which was the maximum temperature allowable per hospital policy. Neonatal hypothermia was defined as core body temperature < 36.5°C (97.7°F) per World Health Organization criteria. The primary study outcome was neonatal hypothermia on arrival to the admitting nursery. Measures of neonatal morbidity potentially associated with hypothermia were examined. Results: Between February and July 2015, 791 women who underwent cesarean deliveries were enrolled, resulting in 410 infants in the 20°C standard management group and 399 in the 23°C study group. The rate of neonatal hypothermia on arrival to the admitting nursery was lower in the study group as compared to the standard management group, 35% versus 50%, p<0.001. Moderate to severe hypothermia was infrequent when the operating room temperature was 23°C (5%); in contrast such hypothermia occurred in 19% of the standard management group, p<0.001. Additionally, neonatal temperature in the operating room immediately following delivery and stabilization was also higher in the study group, 37.1±0.6°C versus 36.9±0.6 °C, p<0.001. We found no difference in rates of intubation, ventilator use, hypoglycemia, metabolic acidemia, or intraventricular hemorrhage. Fever (temperature >38.0°C or 100.4°F) on arrival to the admitting unit was uncommon and did not differ between the study groups. Maternal temperature on arrival to the operating room was not different between the two groups, however by delivery it was significantly lower in the standard management group, 36.2±0.6°C versus 36.4±0.6°C, p<0.001. This effect persisted, as maternal temperature on arrival to the postoperative care area was lower in the standard management group, 36.1±0.6°C versus 36.2±0.6°C, p<0.001, and the rate of hypothermia was higher, 77% versus 69%, p=0.008. Conclusion: A modest increase in operating room temperature at the time of cesarean reduces the rate of neonatal and maternal hypothermia. We did not detect a decrease in neonatal morbidity, but the power to detect a small change in these outcomes was limited.
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Thermal control of the newborn: a practical guide
  • Jan 1996
World Health Organization (WHO). Thermal control of the newborn: a practical guide. In: Maternal Health and Safe Motherhood Programme (WHO/FHE/MSM/93.2). Geneva: WHO, 1996