Effect of Continuously Warmed Irrigating Solution During Transurethral Resection

Transcription

1 Anaesth Intens Care (1988), 16, Effect of Continuously Warmed Irrigating Solution During Transurethral Resection T. HARIOKA,* M. MURAKAWA,t J. NODAt AND K. MORI Department of Anesthesia, Shimada Municipal Hospital, Shizuoka, Japan and Department oj Anesthesiology, Kyoto University School of Medicine, Kyoto, Japan SUMMARY The effects of a continuously warmed irrigating solution on body temperature during transurethral resection of the prostate and of bladder tumours were studied in forty patients. Anaesthesia was spinal and deep body temperatures of the forehead and lower abdomen were measured, using a deep body thermometry system. Bothforehead and lower abdominal deep body temperatures decreased significantly in the patients who underwent transurethral resection of the prostate with an irrigating solution at operating room temperature, but did not decrease in the patients who received a continuously warmed irrigating solution. The same results were obtained for the patients who underwent transurethral resection of bladder tumour. Our results indicate that a continuously warmed irrigating solution could prevent the fall in body temperature during transurethral resection, especially prostate resection, under spinal anaesthesia. Key Words: SURGERY: urological, resection, transurethral, temperature, body, solution, irrigating Irrigating solution, which is used in large quantities during transurethral surgery, is usually at room temperature, and the procedure may be associated with hypothermia and shivering. l. 4 Several investigators have reported a progressive fall in body temperature during transurethral resection of the prostate, and have recommended the use of warm irrigating solution,i,4.6 but the temperature of a prewarmed solution may fall rapidly in a cool operating room.4 Therefore, we have evaluated the effects of a continuously warmed irrigating solution, not simply a prewarmed solution, on body temperature -M.D., Ph.D. tm.d. tm.d., Ph.D. M.D., Ph.D. Address for Reprints: Dr. T. Harioka, Depanment of Anesthesia, Shimada Municipal Hospital, Noda , Shimada, Shizuoka 427, Japan. Accepted for publication February 8, during transurethral resection, comparing it with a solution at room temperature. MATERIALS AND METHODS Twenty patients undergoing transurethral resection of the prostate (TUR-P) and twenty patients, including one woman, undergoing transurethral resection of bladder tumours (TUR-BT) were studied. Each patient gave informed consent for the procedure. The patients undergoing TUR-P were divided into two groups, ten receiving an irrigating solution at room temperature (Group 1) and ten receiving a continuously warmed solution* (Group 2). Similarly, the patients undergoing TUR-BT were divided into two groups, ten receiving a solution at room temperature (Group 3), and ten a warm solution (Group 4). The irrigating solution used for Groups 2 and 4 was maintained at -Vrigal'" which contains Sorbitol 2.7 gll and mannitol 5.4 gll. Anaesthesia and /nrensi,'e Care, Vol. 16, No. 3, August, /988

2 CONTINUOUSLY WARMED IRRIGATION IN TUR 325 TO RESECTSCOPE THERMOSTATIC HEATER THERMOMETER NEEDLE /// THERMISTOR ""'<:---- :,,: ~~tz~~~~:.;:z~20...:.:.:.:.:...:.:.:.:... FIGURE I.-Warming system used in this study. Irrigating solution was warmed and maintained at around 35'C by a thermostatic heater in the reservoir. The temperature of the solution upon entry of the resectoscope was measured using a needle thermistor. about 35 C by a thermostatic heater placed in the solution reservoir (Model TU-I059B, Takei Ikakohki Inc., Osaka), as shown in Figure 1. The anaesthesia was spinal, which is a standard technique for transurethral resection in our hospital to detect early signs of complications, 7 using 0.3% dibucaine, and the upper border of the anaesthesia was at T 1 O. For TUR-BT, an obturator nerve block with 1 % lidocaine was also given for the prevention of adductor muscle spasm. 8 A deep body thermometry system (Terumo Co., Tokyo) was used in this study. The two probes (Type PD-l) of the system were secured with adhesive tape to the midline of the forehead and the midline of the lower abdomen of the patient. After at least twenty minutes of equilibrium, control values of forehead deep body temperature (FDBT) and lower abdominal deep body temperature (LDBT) were obtained, and the operation was started. They were measured again at the end of the procedure. The principle of this thermometry is that the deep body temperature is measured by creating a region of zero heat flow from the core across the body shell, using a heater in the probe. 9 The probe is applied to the skin surface, and causes no discomfort to patients under spinal anaesthesia. We measured FDBT as an approximation of the core temperature, 10,1 I and the LDBT as a reflection of local cooling due to irrigation. It has been reported that, although the FDBT is OSC lower than the wedged nasal temperature, which reflects core temperature, their correlation is significant. ID The operating room and irrigating solution temperatures, and the serum sodium concentration were measured before and after the surgery. The intravenous fluid was not warmed, but a warming mattress with circulating heated water was used. Patients were covered with a hospital sheet to minimise the exposed body surface area, and the operating room temperature was maintained at around 25 C, which is standard in our hospital. All values are expressed as the mean with SD. Preoperative and postoperative values were compared using the Student's t t~st for paired data. Correlation coefficients were calculated between the fall in FDBT and other factors, such as age, body weight, and operating room temperature, in either group. Age, body weight, operating time and the fall in FDBT and LDBT were compared using one-way analysis of variance, followed by the Bonferroni adjustment. Significance was defined as P < RESULTS The demographic profiles of the patients and the duration of the surgery are shown in Table 1. There was no significant difference among the four groups. Measured temperatures and serum sodium concentration are shown in Tables 2 and 3. During TUR-P, the FDBT and LDBT decreased significantly in Group 1, but did not change in Group 2. The fall in serum sodium concentration was significant in Group 1, but the magnitude of the falls was not significantly different between Group 1 and 2. During TUR-BT, similar results were obtained concerning the FDBT and LDBT. The fall in the FDBT correlated with the operating time in Group 1 (P < 0.05) but did not with body weight or age. Figure 2 Anaesthesia and intensive Care. Vol. 16. No. 3. August. 1988

3 326 T. HARIOKA ET AL. TABLE I Patient profiles and the duration of surgery (mean values with SDs in brackets) Group I Group 2 Group 3 Group 4 Number of patients 10 Age (years) 69.6 (11.4) Weight (kg) 53.9 (6.6) Operating time (min) 74.6 (28.5) compares the decrease in FDBT and LBDT among the four groups. The fall in FDBT in Group 1 was significantly larger than that in any other groups, while the decrease in LDBT was larger than in Groups 2 and 4. There were no other significant differences among the groups. No patient experienced shivers or complained of discomfort due to the probes used for deep body thermometry, and there were no complications attributable to the surgery or anaesthesia. The urologist had no difficulty in resection and there was no increase in blood loss due to the warmed solution. DISCUSSION Until recently, even cold irrigating solutions had been considered not to accelerate the fall in body temperature However, significant decreases in oesophageal temperature were found even with room temperature solutions, and an average of 370 kj has been calculated to be lost during the first hour of TUR-P. 2 Chan et al. recommended other means rather than using (S.5) 65.3 (13.9) 71.9 (7.5) 5S.5 (7.3) 56.9 (1\.7) 56.0 (6.9) 59.5 (23.4) 50.2 (12.4) 57.3 (33.4) warmed irrigating solution, because of the surgeon's impression of increased blood loss, but they did not actually measure blood loss.3 In addition, prewarmed irrigating solution has been proved not to increase blood loss and even to be comfortable for surgeons. 15 Therefore, to use warmed irrigating solution is undoubtedly the most reasonable means of preventing heat loss during transurethral resection, and some investigators have emphasised the effect of using warmed irrigating solution during TUR_P. I,5,6 Dyer et al. compared the effect of a reflective blanket and a prewarmed solution, and found that only the combination of the two significantly prevented the fall in sublingual temperature. 4 They also found that the temperature of the solution fell rapidly in a cool operating room. Therefore, we used a continuous warming system to maintain the temperature of the irrigating solution. As for the TUR-P, the patients were lighter and operating time longer in Group 1 than in Group 2, although not significantly. However, those factors did not affect the results, because the fall in FDBT correlated with operating TABLE 2 Temperatures of the operating room, irrigating solution, forehead deep body and abdominal deep body temperatures, and the serum sodium concentration before and after transurethral resection of the prostate (mean values with SDs in brackets) Group I Group 2 Before After Before Room temperature (DC) 25.3 (0.6) 25.2 (0.6) 24.S (0.9) Solution temperature Cc) 23.7 (0,9) 23.7 (0.4) 33.0 (1.9) FDBT Cc) 36.0 (0.5) 35.3 (0.5)t 35.S (0.3) LDBT Cc) 35.0 (0,7) 33.7 (1.5)* 35.5 (0,5) Serum sodium (mmolll) (3.5) 133,8 (4,S)* 136,2 (2.7) After 25.2 (O.S) 32.5 (1.2) 35.7 (0.4) 35.5 (0.6) (6.2) FDBT = forehead deep body temperature; LDBT = lower abdominal deep body temperature. *P< 0.01 as compared with values before surgery. t P < 0.05 as compared with values before surgery. Anaesthesia and Intensive Care, Vol. 16, No. 3, August, 1988

4 CONTINUOUSLY WARMED IRRIGATION IN TUR 327 TABLE 3 Temperatures of the operating room, irrigating solution, forehead deep body and lower abdominal deep body temperatures, and the serum sodium concentration before and after transurethral resection of bladder tumours (mean values with SDs in brackets) Group 3 Group 4 Before After Before After Room temperature (0C) 25.2 (0.5) 25.0 (0.8) 25.9 (1.0) 25.6 (1.0) Solution temperature ("C) 23.2 (0.8) 23.2 (0.9) 31.6 (3.7) 32.9 (2.9) FDBT (0C) 35.7 (0.2) 35.5 (0.3)t 35.5 (0.3) 35.5 (0.3) LDBT ("C) 35.0 (0.6) 34.4 (1.1)* 35.0 (0.9) 35.0 (0.5) Serum sodium (mmolll) (2.3) (1.6) (3.3) (5.2) FDBT = forehead deep body temperature; LDBT = lower abdominal deep body temperature. * p < 0.05 as compared with values before surgery. tp < 0.01 as compared with values before surgery. time only in Group 1, and did not correlate with body weight in any group. The decrease in FDBT in Group 3 was significantly smaller than in Group 1. This suggests that local cooling itself did not decrease FDBT, but that other factors, such as a larger volume of irrigating solution or intravascular absorption of the irrigating 2 solution, also played a role during TUR-P. In either case, using a continuously warmed irrigating solution would cancel the effects of such factors. Several factors other than the irrigating solution temperature aggravate the decrease in body temperature during transurethral resection. One is spinal anaesthesia, which has 2 --:-- t* -- t -: +* -: t* -4 ~ ~ -L ~ ~ GI c: IV r. u Group 1 Group 2 Group 3 Group 4 Group 1 Group 2 Group 3 Group 4 FIGURE 2.-Mean changes in forehead and lower abdominal deep body temperatures in the four patient groups. The error bars indicate standard deviations and the asterisks denote a significantly different change compared with Group 1 (P< 0.01). Anaesthesia and Intensi"e Care. Vol. 16. No. 3. August. 1988

5 328 T. HARIOKA ET AL. been recommended for this operation. The body temperature decreases faster and to a greater degree in the patients under spinal or epidural anaesthesia than in the patients under general anaesthesia, and recovery from postoperative hypothermia is slower. 2,16,17 Another factor is that patients who undergo transurethral resection, especially TUR-P, are generally elderly, and tend to exhibit more pronounced and prolonged hypothermia. 2,17,18 In conclusion, this study has shown that the use of a continuously warmed solution, combined with other means, such as an operating room temperature of 25 C and the use of an active warming mattress, is effective in preventing hypothermia during transurethral resection under spinal anaesthesia, especially during TUR-P. The effect in patients under other anaesthesia techniques remains unclear. REFERENCES 1. Carpenter AA. Hypothermia during transurethral resection of prostate. Urology 1984; 23: Stjernstrom H, Henneberg S, Eklund A, Tabow F, Arturson G, Wiklund L. Thermal balance during transurethral resection of the prostate. A comparison of general anaesthesia and epidural analgesia. Acta Anaesthesiol Scand 1985; 29: Ch an CS, Mok YH. Shivering during transurethral resection of the prostate under spinal analgesia. Singapore Med J 1986; 27: Dyer PM, Heathcote PS. Reduction of heat loss during transurethral resection of the prostate. Anaesth Intens Care 1986; 14: Alien TD. Body temperature changes during prostatic resection as related to the temperature of the irrigating solution. J Urol 1973; 110: Rabke HB, Jenicek JA, Khouri E. Hypothermia associated with transurethral resection of the prostate. J Urol 1962; 87: Marx GF, Orkin LR. Complications associated with transurethral surgery. Anesthesiology 1962; 23: Gasparich JP, Mason JT, Berger RE. Use of nerve stimulator for simple and accurate obturator nerve block before transurethral resection. J U rol 1984; 132: Vale RJ. Monitoring of temperature during anesthesia. Int Anesthesiol Cl in 1981; 19: Muravchick S. Deep body thermometry during general anesthesia. Anesthesiology 1983; 58: Togawa T, Nemoto T, Yamazaki T, Kobayashi T. A modified internal temperature measurement device. Med Bioi Eng 1976; 14: Franks DP, Cockett AT. Local hypothermia of the urinary bladder during transurethral surgery. Anesthesiology 1961; 22: Rawstron RE, Walton JK. Body temperature changes during transurethral prostatectomy. Anaesth Intens Care 1981; 9: Kulatilake AE, Roberts PN, Evans DF, Wright J. The use of cooled irrigating fluid for transurethral prostatic resection. Br J Urol 1981; 53: Heathcote PS, Dyer PM. The effect of warm irrigation during transurethral prostatectomy under spinal anaesthesia. Br J Urol 1986; 58: Jenkins J, Fox J, Sharwood-Smith G. Changes in body heat during transvesical prostatectomy. A comparison of general and epidural anaesthesia. Anaesthesia 1983; 38: Vaughan MS, Vaughan RW, Cork RC. Postoperative hypothermia in adults: relationship of age, anesthesia, and shivering to rewarming. Anesth Analg 1981; 60: Reuler JB. Hypothermia: pathophysiology, clinical settings, and management. Ann Intern Med 1978; 89: Anaesthesia and InlensNe Care. Vol. 16. No. 3. August. 1988