General anesthesia: a comparison between upper- and lower-body warming

1. 2. 3. 4. AHMED A. SHORRAB, MOHAMED E. EL-SAWY, MAHMOUD M. OTHMAN, GOLINAR E. HAMMOUDA

DOI: 10.1111/j.1460-9592.2006.02006.x Article first published online: 26 JUN 2006

Pediatric Anesthesia
Volume 17, Issue 1, pages 3843, January 2007

Summary
Background : Children receiving combined epidural and general anesthesia may be at greater risk of hypothermia. Active warming should be undertaken to combat heat loss. With combined epidural and general anesthesia heat loss from the lower body may be greater than from the upper body because of shift of blood towards the vasodilated lower body. We assumed that application of the warming blanket to the lower body might provide better protection against hypothermia. To test this hypothesis, lower-body warming (LBW) was compared with upper-body warming (UBW) in a randomized comparative study. Methods: Children subjected to open urologic surgery under combined epidural and general anesthesia were randomly allocated to either UBW n = 38 or LBW n = 35 using a forced-air warming blanket. Core and peripheral skin temperatures were monitored. Temperature gradients between

forearm and fingertip during LBW and between leg and toe during UBW were calculated. The warmer was set at 32C, room temperature was around 22C and fluids were infused at ambient room temperature. Results : The changes in core temperature were comparable and parallel in both groups. Core temperature decreased significantly in each group at 1 h after induction compared with basal values. Temperature gradients at forearm-fingertip and at leg-toe were also comparable in both groups. Recovery was uneventful and no patient shivered in the recovery room. Conclusions : Lower body warming is as effective as UBW in prevention of hypothermia in children subjected to combined epidural and general anesthesia.
http://onlinelibrary.wiley.com/doi/10.1111/j.14609592.2006.02006.x/abstract;jsessionid=DD01F8B5197DF90DDAC157E94CD4FE2F.d01t04?userIsAuth enticated=false&deniedAccessCustomisedMessage=

Use of plastic bags to prevent hypothermia at birth in preterm infants-do they work at lower gestations?
1. CPH Ibrahim, 2. CW Yoxall Article first published online: 21 OCT 2008 DOI: 10.1111/j.1651-2227.2008.01076.x 2008 The Author(s)/Journal Compilation 2008 Foundation Acta Pdiatrica/Acta Pdiatrica Issue

Acta Paediatrica
Volume 98, Issue 2, pages 256260, February 2009

Abstract
Background: Hypothermia at birth is strongly associated with mortality and morbidity in preterm infants. Occlusive wrapping of preterm infants during resuscitation, including polythene bags have been shown to prevent hypothermia. Objectives : To evaluate the effectiveness of the introduction of polythene bags at resuscitation of infants born below 30 weeks gestation in a large tertiary neonatal centre.

Methods : Retrospective audit of admission temperatures of all infants born below 30 weeks gestation for two years before and two years after the introduction of polythene bags. Hypothermia was defined as admission axillary temperature < 36C. Results : A total of 334 eligible infants were born during the study period. Two hundred and fifty-three (75.8%) had admission temperatures recorded. The incidence of hypothermia fell from 25% to 16%(p = 0.098) for the whole group since the introduction of polythene bags. The main reduction in hypothermia was seen in infants born above 28 weeks gestation (19.4% vs. 3.9%, p = 0.017). There was no significant effect in infants born between 28 weeks and 30 weeks (29.3% vs. 24.8%, p = 0.58). Conclusions : Polythene bags are effective in reducing the incidence of hypothermia at admission in infants born below 30 weeks gestation. The benefit in infants born below 28 weeks gestation was only marginal. This is in contrast to previously published studies. This may be related to the comparatively low incidence of hypothermia at the study centre even prior to introduction of polythene bags.

Warming preterm infants in the delivery room: polyethylene bags, exothermic mattresses or both?
1. Lisa K McCarthy1,2,3, 2. Colm PF ODonnell1,2,3 Article first published online: 4 OCT 2011 DOI: 10.1111/j.1651-2227.2011.02375.x 2011 The Author(s)/Acta Pdiatrica 2011 Foundation Acta Pdiatrica Issue

Acta Paediatrica
Volume 100, Issue 12, pages 15341537, December 2011

Keywords:

Exothermic mattress; Hypothermia; Infant; Polyethylene bag; Premature

Abstract
Aims : To compare the admission temperature of infants treated with polyethylene bags alone to infants treated with exothermic mattresses in addition to bags in the delivery room.

Methods : We prospectively studied infants born at <31 weeks gestation who were placed in bags at birth. Some infants were also placed on mattresses. Admission axillary temperatures were measured in all infants on admission to the neonatal intensive care. We compared the temperatures of infants treated with bags alone to those treated with mattresses and bags. Results : We studied 43 infants: 15 were treated with bags while 28 were treated with a bag and mattress. Mean admission temperature was similar between the groups. Hypothermia and hyperthermia occurred more frequently in infants treated with a bag and mattress, and more infants treated with a bag had admission temperatures 36.537.5C. Conclusion : The use of exothermic mattresses in addition to polyethylene bags, particularly in younger, smaller newborns, may result in more hypothermia and hyperthermia on admission. A randomised controlled trial is necessary to determine which strategy results in more infants having admission temperatures in the normal range. http://onlinelibrary.wiley.com/doi/10.1111/j.16512227.2011.02375.x/abstract?userIsAuthenticated=false&deniedAccessCustomisedMessage=

Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants

1. 2. 3. 4. 5. Emma M McCall1,*, Fiona Alderdice2, Henry L Halliday3, John G Jenkins4, Sunita Vohra5

Editorial Group: Cochrane Neonatal Group Published Online: 8 OCT 2008 Assessed as up-to-date: 12 SEP 2007 DOI: 10.1002/14651858.CD004210.pub3 Copyright 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Abstract
Background Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), associated with morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite. Objectives To assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birthweight infants applied within ten minutes after birth in the delivery suite compared with routine thermal care. Search strategy The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to July Week 4 2007 ), CINAHL (1982 to July Week 4 2007), EMBASE (1974 to 01/08/2007), the Cochrane Central Register of Controlled Trials

(CENTRAL, The Cochrane Library, Issue 3, 2007), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2007), conference/symposia proceedings using ZETOC (1993 to 17/08/2007), ISI proceedings (1990 to 17/08/2007) and OCLC WorldCat (July 2007). Identified articles were cross-referenced. No language restrictions were imposed. Selection criteria All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight 2500 g. Data collection and analysis Methodological quality was assessed and data were extracted for important clinical outcomes including adverse effects of the intervention by at least three independent review authors. Authors were contacted for missing data. Data were analysed using RevMan 4.2.5. Relative risk (RR), risk difference (RD) and number needed to treat (NNT) with 95% confidence limits were calculated for each dichotomous outcome and mean differences (MD) with 95% confidence limits for continuous outcomes. Main results Six studies giving a total of 304 infants randomised and 295 completing the studies were included. Four comparisons to 'routine care' were undertaken within two categories: 1) barriers to heat loss (four studies): plastic wrap or bag (three), stockinet caps (one) and 2) external heat sources (two studies): skin-to-skin (one), transwarmer mattress (one). Plastic barriers were effective in reducing heat losses in infants < 28 weeks' gestation (three studies, n = 159; WMD 0.76 C; 95% CI 0.49, 1.03), but not in infants between 28 to 31 week's gestation. There was insufficient evidence to suggest that plastic wrap reduces the risk of death within hospital stay (three studies, n = 161; typical RR 0.63; 95% CI 0.32, 1.22; typical RD 0.09; 95% CI -0.20, 0.03). There was no evidence of a significant difference in major brain injury, mean duration of oxygen therapy or hospitalisation for infants < 29 weeks' gestation. Stockinet caps were not effective (borderline significant for infants < 2000 g birthweight) in reducing heat losses. Skin-to-skin care was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants 1200 to 2199 g birthweight (one study, n = 31; RR 0.09; 95% CI 0.01, 0.64; NNT 2; 2 to 4). The transwarmer mattress kept infants 1500 g significantly warmer and reduced the incidence of hypothermia on admission to NICU (one study, n = 24; RR 0.30; 95% CI 0.11, 0.83; NNT 2 range 2 to 4).

Authors' conclusions Plastic wraps or bags, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia. Given the low NNT, consideration should be given to using these interventions in the delivery suite. However, the small numbers of infants and studies and the absence of long-term follow-up mean that firm recommendations for clinical practice cannot be given. There is a need to conduct large, high quality randomised controlled trials looking at long-term outcomes.

Heat Loss Prevention in Very Preterm Infants in Delivery Rooms: A Prospective, Randomized, Controlled Trial of Polyethylene Caps
The Journal of Pediatrics
Volume 156, Issue 6 Pages 914-917.e1 Daniele Trevisanuto, Nicoletta Doglioni, Francesco Cavallin, Matteo Parotto, Massimo Micaglio, Vincenzo Zanardo

Abstract
Objective To evaluate in preterm infants whether polyethylene caps prevent heat loss after delivery better than polyethylene occlusive wrapping and conventional drying. Study design This was a prospective, randomized, controlled trial of infants <29 weeks' gestation including 3 study groups: (1) experimental group in which the heads of patients were covered with a polyethylene cap; (2) polyethylene occlusive skin wrap group; and (3) control group in which infants were dried. Axillary temperatures were compared at the time of admission to the neonatal intensive care unit (NICU) immediately after cap and wrap removal and 1 hour later. Results The 96 infants randomly assigned (32 covered with caps, 32 wrapped, 32 control) completed the study. Mean axilllary temperature on NICU admission was similar in the cap group (36.1C 0.8C) and wrap group (35.8C 0.9C), and temperatures on admission to the NICU were significantly higher than in the control group (35.3C 0.8C; P < .01). Infants covered with polyethylene caps (43%) and placed in polyethylene bags (62%) were less likely to have a temperature <36.4C on admission to the NICU than control infants (90%). In the cap group, temperature 1 hour after admission was significantly higher than in the control group.

Conclusions For very preterm infants, polyethylene caps are comparable with polyethylene occlusive skin wrapping to prevent heat loss after delivery. Both these methods are more effective than conventional treatment.
Copyright 2009 Elsevier B.V. All rights reserved.

http://linkinghub.elsevier.com/retrieve/pii/S0022347609012505?via=sd&cc=y

Original Article
Journal of Perinatology (2005) 25, 304308. doi:10.1038/sj.jp.7211289

Heat Loss Prevention for Preterm Infants in the Delivery Room

This research was partially supported by National Institute for Nursing Research T32 NR07091 Interventions to Prevent and Manage Chronic Illness. Robin B Knobel RNC, MSN, NNP1, John E Wimmer Jr MD2 and Don Holbert PhD3
1. Children's Hospital (R.B.K.), University Health Systems of Eastern Carolina and University of North Carolina, Chapel Hill, USA 2. 2Neonatal Medicine (J.E.W.), Women's Hospital of Greensboro, Greensboro, NC, USA 3. 3Department of Biostatistics (D.H.), School of Allied Health Sciences, East Carolina University, USA.
1

Correspondence : John E Wimmer Jr., MD, Neonatal Medicine, Women's Hospital of Greensboro, 801 Green Valley Rd, Greensboro NC 27408, USA.

Abstract
OBJECTIVE: Preterm infants are prone to hypothermia immediately following birth. Among other factors, excessive evaporative heat loss and the relatively cool ambient temperature of the delivery room may be important contributors. Most infants <29 weeks gestation had temperatures <36.4C on admission to our neonatal unit (NICU). Therefore we conducted a randomized, controlled trial to evaluate the effect of placing these infants in polyurethane bags in the delivery room to prevent heat loss and reduce the occurrence of hypothermia on admission to the NICU. METHODS: After parental consent was obtained, infants expected to be <29 weeks gestation were randomized to intervention or control groups just prior to their birth. Infants randomized to the intervention group were placed in polyurethane bags up to their necks immediately after delivery before being dried. They were then resuscitated per NRP guidelines, covered with warm blankets, and transported to the NICU, where the bags were removed and rectal temperatures were recorded. Control infants were resuscitated, covered with warm blankets, and transported without being placed in polyurethane bags. Delivery room temperatures were recorded so this potentially confounding variable could be assessed.

RESULTS: Intervention patients were less likely than control patients to have temperature < 36.4C on admission , 44 vs 70% (p<0.01) and the intervention group had a higher mean admission temperature, 36.5C vs 36.0C (p<0.003). This effect remained significant (p<0.0001) when delivery room temperature was controlled in analysis. Warmer delivery room temperatures ( 26C) were associated with higher admission temperatures in both intervention and control infants, but only the subgroup of intervention patients born in warmer delivery rooms had a mean admission temperature >36.4C. CONCLUSIONS: Placing infants <29 weeks gestation in polyurethane bags in the delivery room reduced the occurrence of hypothermia and increased their NICU admission temperatures. Maintaining warmer delivery rooms helped but was insufficient in preventing hypothermia in most of these vulnerable patients without the adjunctive use of the polyurethane bags.

http://www.nature.com/jp/journal/v25/n5/abs/7211289a.html

Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns
1. NJ Bergman1,*, 2. LL Linley1,2, 3. SR Fawcus1,3 Article first published online: 2 JAN 2007 DOI: 10.1111/j.1651-2227.2004.tb03018.

Keywords:

Hypothermia; prematurity; separation; skin-to-skin contact; stability

Aim : Conventional care of prematurely born infants involves extended maternal-infant separation and incubator care. Recent research has shown that separation causes adverse effects. Maternal-infant skin-to-skin contact (SSC) provides an alternative habitat to the incubator, with proven benefits for stable prematures; this has not been established for unstable or newborn low-birthweight infants. SSC from birth was therefore compared to incubator care for infants between 1200 and 2199 g at birth. Methods : This was a prospective, unblinded, randomized controlled clinical trial; potential subjects were identified before delivery and randomized by computerized minimization technique at 5 min if eligible. Standardized care and observations were maintained for 6 h. Stability was measured in terms of a set of pre-determined physiological parameters, and a composite cardio-respiratory stabilization score (SCRIP).

Results : 34 infants were analysed in comparable groups: 3/18 SSC compared to 12/13 incubator babies exceeded the pre-determined parameters (p < 0.001). Stabilization scores were 77.11 for SSC versus 74.23 for incubator (maximum 78), mean difference 2.88 (95% CI: 0.35.46, p = 0.031). All 18 SSC subjects were stable in the sixth hour, compared to 6/13 incubator infants. Eight out of 13 incubator subjects experienced hypothermia. Conclusion : Newborn care provided by skin-to-skin contact on the mother's chest results in better physiological outcomes and stability than the same care provided in closed servo-controlled incubators. The cardio-respiratory instability seen in separated infants in the first 6 h is consistent with mammalian protest-despair biology, and with hyper-arousal and dissociation response patterns described in human infants: newborns should not be separated from their mothers.

onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2004.tb03018.x/abstract

Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings
1. A Cattaneo1,*, 2. R Davanzo1, 3. B Worku2, 4. A Surjono3, 5. M Echeverria4, 6. A Bedri2, 7. E Haksari3, 8. L Osorno4, 9. B Gudetta2, 10. D Setyowireni3, 11. S Quintero1, 12. G Tamburlini1 Article first published online: 2 JAN 2007 DOI: 10.1111/j.1651-2227.1998.tb01769.x

Keywords:

Developing countries; kangaroo mother care; low birthweight infants

A randomized controlled trial was carried out for 1 y in three tertiary and teaching hospitals, in Addis Ababa (Ethiopia), Yogyakarta (Indonesia) and Merida (Mexico), to study the effectiveness, feasibility, acceptability and cost of kangaroo mother care (KMC) when compared to conventional methods of care (CMC). About 29% of 649 low birthweight infants (LBWI; 1000-1999 g) died before eligibility. Of the survivors, 38% were excluded for various reasons, 149 were randomly assigned to KMC (almost exclusive skin-to-skin care after stabilization), and 136 to CMC (warm room or incubator care). There were three deaths in each group and no difference in the incidence of severe disease. Hypothermia was significantly less common in KMC infants in Merida (13.5 vs 31.5 episodes/100 infants/d) and overall (10.8 vs 14.6). Exclusive breastfeeding at discharge was more common in KMC infants in Merida (80% vs 16%) and overall (88% vs 70%). KMC infants had a higher mean daily weight gain (21.3 g vs 17.7 g) and were discharged earlier (13.4 vs 16.3 d after enrolment). KMC was considered

feasible and presented advantages over CMC in terms of maintenance of equipment. Mothers expressed a clear preference for KMC and health workers found it safe and convenient. KMC was cheaper than CMC in terms of salaries (US$ 11 788 vs US$ 29 888) and other running costs (US$ 7501 vs US$ 9876). This study confirms that hospital KMC for stabilized LBWI 10001999 g is at least as effective and safe as CMC, and shows that it is feasible in different settings, acceptable to mothers of different cultures, and less expensive. Where exclusive breastfeeding is uncommon among LBWI, KMC may bring about an increase in its prevalence and duration, with consequent benefits for health and growth. For hospitals in low-income countries KMC may represent an appropriate use of scarce resources.

http://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.1998.tb01769.x/abstract

Original Article

Experience with Kangaroo mother care in a neonatal intensive care unit (NICU) in Chandigarh, India
Veena Rani Parmar, Ajay Kumar, Rupinder Kaur, Siddharth Parmar, D. Kaur, Srikant Basu, Suksham Jain and Sunny Narula

Abstract
Objective To study the feasibility and acceptability of Kangaroo mother care (KMC) on the low birth weight infants (LBWI) in the neonatal intensive care unit (NICU) by the mothers, family members and health care workers (HCW) and to observe its effect on the vital parameters of the babies. Method A observation in the NICU. Results A total of 135 babies (74 boys and 61 girls) who completed minimum of 4 hrs of KMC/day, were included. The mean birth weight and gestation were 1460gm and 30 week respectively. 47% babies started KMC within first week of age. Mean duration of KMC was 7 days (348) days. The O2 saturation improved by 23%, temperature (C) rose from 36.75 0.19 to 37.23 0.25, respiration stabilized (p<0.05 for all) and heart rate dropped by 35 beats. No episodes of hypothermia or apnea were observed during KMC. KMC was accepted by 96 % mothers, 82% fathers and 84% other family members. 94% HCW considered it to be safe and conservative method of care of LBWI. Benefits of KMC on the babies behavior and on maternal confidence and lactation were reported by 57%, 94% and 80% respectively. A decline in use of heating devices in the NICU was reported by 85% and 79% said it did not increase their work load.

Conclusion KMC was found to be safe, effective and feasible method of care of LBWI even in the NICU settings. Positive attitudes were observed in mothers, families and HCW

http://www.springerlink.com/content/k031777349l34381/

A comparison of kangaroo mother care and conventional incubator care for thermal regulation of infants < 2000 g in Nigeria using continuous ambulatory temperature monitoring
Authors : Ibe, O.E.1; Austin, T.2; Sullivan, K.3; Fabanwo, O.2; Disu, E.2; Costello, A.M. de L.3 Source : Annals of Tropical Paediatrics: International Child Health, Volume 24, Number 3, September 2004 , pp. 245-251(7)

Publisher : Maney Publishing Publication date : 2004-09-01 DOI : http://dx.doi.org/10.1179/027249304225019082 Document Type : Research Article

Abstract: Although skin-to-skin contact (or kangaroo mother care, KMC) for preterm infants is a practical alternative to incubator care, no studies have compared these methods using continuous ambulatory temperature monitoring. To compare thermal regulation in low birthweight infants (< 2000 g) managed by KMC alternating with conventional care (CC) and to determine the acceptability to mothers of KMC, an experimental study with a crossover design with observational and qualitative data collected on temperature patterns and mothers attitudes to skin-to-skin care was conducted in the neonatal wards of three hospitals in Lagos, Nigeria. Thirteen eligible infants were nursed by their mothers or surrogates in 38 4-hour sessions of KMC and the results compared with 38 sessions of incubator care. The risk of hypothermia was reduced by > 90% when nursed by KMC rather than conventional care, relative risk (RR) 0.09 (0.030.25). More cases of hyperthermia (> 37.5C) occurred with KMC, and coreperiphery temperature differences were widened, but the risk of hyperthermia > 37.9C (RR 1.3, 0.91.7) was not significant. Micro-ambient temperatures were higher during KMC, although the average room temperatures during both procedures did not differ significantly. Mothers felt that KMC was safe, and preferred the method to CC because it did not separate them from their infants,

although some had problems adjusting to this method of care. Where equipment for thermal regulation is lacking or unreliable, KMC is a preferable method for managing stable low birthweight infants. Affiliations: 1: POLICY Project, Abuja, Nigeria 2: Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria 3: International Perinatal Care Unit, Institute of Child Health, University College London, UK

http://www.ingentaconnect.com/content/maney/atp/2004/00000024/00000003/art00008