Effects of sympathetic blockade on the efficiency of forced-air warming during combined spinal-epidural anesthesia for total hip arthroplasty

Abstract

Study Objective: To evaluate if active cutaneous warming of the two upper limbs with reflex vasoconstriction is less effective in maintaining intraoperative normothermia than warming the vasodilated unoperated lower limb during combined spinal-epidural anesthesia (CSE). Design: Prospective, randomized study. Setting: Inpatient anesthesia at university departments of orthopedic surgery. Patients: 48 ASA physical status I, II, and III patients, who were scheduled for elective total hip arthroplasty. Interventions: Patients received CSE with intrathecal injection of 15 mg of 0.5% hyperbaric bupivacaine. All procedures started 8 to 10 am, and operating room temperature was maintained between 21° and 23°C, with relative humidity ranging between 40% and 45%. For warming therapy, patients received active forced-air warming of either the two upper limbs (Group Upper body, n = 24), or the unoperated lower limb (Group Lower extremity, n = 24). Core temperature was measured before CSE placement (baseline), and then every 30 minutes until completion of surgery. Time for fulfillment of clinical discharging criteria from the recovery area was evaluated by a blinded observer. Measurements and Main Results: Demographic data, duration of surgery, intraoperative blood losses, crystalloid infusion, and hemodynamic variables were similar in the two groups. Core temperature slightly decreased in both groups, but at the end of surgery the mean core temperature was 36.2° ± 0.5°C in Group Upper body and 36.3 ± 0.5 in Group Lower extremity (NS). At recovery room arrival, seven patients in Group Upper body (29%) and three patients in Group Lower extremity (12.5%) had a core temperature less than 36°C (NS). Shivering was observed in one patient in Group Upper body and in two patients in Group Lower extremity (NS). Clinical discharging criteria were fulfilled after 37 ± 16 minutes in Group Upper body and 30 ± 32 minutes in Group Lower extremity (NS). Conclusions: Forced-air cutaneous warming allows the anesthesiologist to maintain normothermia during CSE for total hip replacement even if the convective blanket is placed on a relatively small skin surface with reflex vasoconstriction. Placing the forced-air warming system on the vasodilated unoperated lower limb may be troublesome to the surgeons and does not offer clinically relevant advantages in warming efficiency.