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Chapter 29

Temperature Monitoring
Indications for Temperature Monitoring
Numerous studies have shown that si gni f icant t emperature changes routi nel y occur
i n anestheti zed pati ents (1,2,3). The moni tori ng guidel i nes of the Ameri can Soci ety
of Anesthesi ologists st ate that Every pati ent recei vi ng anesthesi a shal l have
t emperat ure moni t ored when cl i nical l y si gnif i cant changes in body temperature are
i ntended, ant i cipat ed or suspected. The Standards for Nurse Anesthesi a Practi ce
stat e that one must moni tor body temperature conti nuousl y on al l pediat ric pat i ents
receivi ng general anest hesi a and, when i ndi cat ed, on all other pati ents (3A).
Temperature moni tori ng shoul d be perf ormed whenever l arge vol umes of col d bl ood
and/or i ntravenous f l ui ds are admi ni st ered, when t he pat i ent i s del i beratel y cool ed
and/or warmed, f or pediatric surgery of substanti al durat i on, and in hypothermic or
pyrexi al pat ients or those wi th a suspected or known t emperat ure regul atory
probl em such as mali gnant hyperthermi a. Maj or surgical procedures, especial l y
t hose i nvolving body cavit i es, shoul d be consi dered a strong i ndi cati on for
t emperat ure moni t ori ng.
Standards
A U.S. standard f or el ect ronic t hermometers, not i ncl uding i nf rared t hermometers,
was publ ished i n 2000 (4). Celsi us display thermomet ers must be graduated in
i ntervals of not greater t han 0.1C, whi l e thermomet ers usi ng a Fahrenhei t displ ay
must be graduat ed i n int erval s of not greater t han 0.2F. The maxi mum error f or an
i ndi vi dual readi ng is shown i n Tabl e 29.1.
There i s also a U.S. standard f or i nf rared t hermomet ers (5). Thi s specif i cat ion does
not prescribe a method f or determi ning cl i ni cal accuracy.
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TABLE 29.1 Maximum Error for Electronic Thermometers
Temperature Maximum Error
Celsius Scale
Less than 35.8C 0.3F
35.8C to less than 37.0C 0.2F
37.0C to 39.0C 0.1F
39.0C to 41.0C 0.2F
Greater than 41.0C 0.3F
Fahrenheit Scale
Less than 96.4C 0.5F
96.4C to 98.0C 0.3F
98.0C to 102.0C 0.2F
102.0C to 106.0C 0.3F
Greater than 106.0C 0.5F
(From ASTM 15111200, 2000).

Technologies
A variety of t echnol ogi es are avai l abl e to measure temperature. None is sui t abl e for
al l si t uat ions. Many devi ces simpl y di spl ay the temperature. These are l ess than
opti mal , because a hi gh or l ow temperature may go unnoti ced f or some ti me. Most
modern devices have alarms that can be set i f t he temperature exceeds high or l ow
l i mi ts. Temperat ure-moni tori ng capabi l i ty i s avai l abl e on most physiol ogic moni tors
used i n the operat ing room and peri operat ive areas. Frequent l y, t hey have the
abi l i t y to measure temperature at t wo dif f erent si tes (Fi g. 29.1). These devices
usual l y have the abi l i ty t o trend t he temperature and t o transf er t emperat ure
i nformati on to an el ectroni c record.
There are a number of st and-al one devi ces, both mechanical and chemi cal . Those
stand-al one devi ces t hat are bat t ery-powered should have a means to i ndicate
when batt ery power i s l ow. Trend i ndi cators are avai labl e on some of these
i nst ruments.
Thermistor
A thermi st or i s composed of a met al (i . e. , manganese, ni ckel , cobal t , i ron, or zi nc)
oxide sint ered into a wi re or f used i nto a rod or bead (6,7). There must be a source
of current and a means to measure t hat current . Resistance of the metal oxi de
i ncreases as the temperat ure decreases and vi ce versa so t he resi st ance can be
converted to a temperature. Advantages of t hermistors incl ude smal l si ze, rapi d
response ti me, cont inuous readings, and sensi t ivi t y to smal l changes i n
t emperat ure. They are fai rl y i nexpensive. Probes can be interchangeabl e and
di sposabl e.

View Figure

Figure 29.1 Monitor with capability for monitoring
temperature at two sites and alarms. (Courtesy of Fisher
Paykel Healthcare.)

Thermocouple
A thermocoupl e consi sts of an el ect ri cal ci rcui t that has t wo di ssi mi l ar met al s
wel ded t ogether at t hei r ends (6,8). One of t he two metal j uncti ons remai ns at a
const ant t emperat ure. The ot her is exposed to t he area bei ng measured, produci ng
a vol t age di ff erence that i s measured and converted to a temperature readi ng.
Advantages of thermocoupl es i ncl ude accuracy, smal l size, rapi d response t i me,
conti nuous readi ngs, stabi li t y, and probe i nterchangeabi l i ty. The materi al s are
i nexpensive, so the probes can be made di sposabl e.
Platinum Wire
The el ectrical resi stance of pl ati num wi re vari es al most l i nearl y wi t h temperature.
By empl oying an extremel y smal l diameter wi re, rapi d t hermal equi l i brat ion i s
possi bl e. Resistance is measured in a manner si mi lar to a thermi stor. These
t hermometers are accurate and gi ve cont inuous readi ngs. Probes can be made
i nterchangeabl e.
I f a probe wi t h a t hermocoupl e, t hermistor, or plati num wi re i s to be used i nsi de the
body, i t must have
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an outer sheath. The end of t he probe desi gned to be insert ed i nto the pati ent i s
sealed and the el ectri cal connecti on made at the other end. The connecti on needs
t o be kept dry. If i t becomes wet, erroneous readings can resul t (9,10,11).

View Figure

Figure 29.2 The flexible adhesive-backed strip of this
liquid crystal temperature monitor has a black background.
To use, the covering over the adhesive is removed, and the
monitor is placed on the skin.

Liquid Crystal
Certai n organic compounds in thermal t ransf ormati on f rom a sol i d to a l iqui d state
pass through an intermedi ate phase t hat exhi bi ts anisot ropic (opt ical l y acti ve)
propert ies (12, 13). The term l iqui d crystal is used to descri be thi s st ate. When l ight
shines on such a mat erial , crystals scatt er some of t he l i ght , produci ng i ridescent
colors. The li qui d crystal s are encapsul at ed so that the col ors f orm l et ters and
numbers.
A l i qui d cryst al t emperature moni tor i s shown in Fi gure 29.2. I t consi sts of a fl exi bl e
adhesive backi ng wi th pl ast i c-encased l i quid cryst al s on a bl ack background that
prevents ref lecti on of t he t ransmi t t ed li ght and enhances the color resol uti on. The
coveri ng over t he adhesive i s removed, and the di sc or st ri p i s pl aced on the ski n.
The l i qui d crystal t hermometer is avai lable i n two f orms: one di splays the ski n
t emperat ure di rect l y; the other has a bui l t-in correcti on f actor (of f set ) so that t he
t emperat ure di spl ayed est i mates core temperature (7, 13).
Li qui d crystal thermomet ers are safe, conveni ent , noni nvasive, easy to appl y and
read, disposabl e, noni rri t ati ng, and i nexpensive. They gi ve f ast , conti nuous
readi ngs and invol ve no el ect ronic ci rcui t ry. They can be appl i ed bef ore i nducti on
of anest hesi a and are easi l y t ransf erred to the recovery area wi th t he pat ient.
Di sadvantages of l iquid crystal thermomet ers incl ude the need f or subjecti ve
observer i nterpretat ion and the i nabil i ty t o int erf ace wi t h a recordi ng system. They
are less accurate than other devi ces. Ext reme ambi ent temperature, humi di t y, and
ai r movement can cause i naccuracy (13). Ot her disadvantages i ncl ude di f fi cul ti es
wi th adhesi on secondary t o ski n secreti ons, al l ergi c reacti ons to adhesi ve backi ng,
i naccuracy, and imprecision (14,15). They are capabl e of measuring t emperature
onl y on the ski n. I f l ef t in t he sun f or an extended peri od, an error i ndi cat ing
hyperthermi a can be produced. I f the device i s f rozen, al l t he numbers can be
vi si bl e at once (13). I nf rared heati ng l amps may cause erroneously el evated
readi ngs (12). There i s a report of a l i qui d cryst al t hermometer that gave a f al sel y
hi gh temperature (16).
Infrared
An i nf rared thermometer is an el ectroni c instrument that measures a port i on of t he
i nf rared radiati on f rom surfaces wi thi n i ts f ield of view (17, 18,19). El ect romagneti c
radi ati on i s emi t t ed by an obj ect in proport ion to i ts temperature. Because the
probe i s pl aced i n the outer part of t he ear canal and usual l y has a rel ati vely wi de
vi ew angle, i t detects i nf rared emi ssions f rom part s of both t he ear canal wal l and
t ympanic membrane and computes an average or hi ghest t emperature. The
di spl ayed val ue may be t he act ual temperature (unadj usted, cal ibrat i on mode) or
wi th an of f set t o est imate temperature at anot her si t e based on sel ect ed study
sampl es (si te equi val ent mode) (5,7,17,20).
The i nst rument has an otoscopel ike probe (Fi g. 29.3). Di sposabl e probe covers are
used for hygi ene and to prevent cerumen bui l dup. The probe shoul d be pl aced
caref ul l y but fi rml y as f ar as possi bl e into the ear canal , ai mi ng toward the
t ympanic membrane. The probe wi ndow shoul d be cl ean and shi ny, and a new
probe cover shoul d be used each ti me.

View Figure

Figure 29.3 The infrared thermometer's probe is inserted
into the external ear canal.

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Pat i ents tol erate i nf rared t hermomet ry wel l (18). Because i t does not contact any
surf ace, there shoul d be no trauma associ ated wi th i ts use. Measurements are
rapi d. Thi s technology is of t en used i n the post anesthesi a care uni t and ot her
cri t i cal care areas.
There are a number of probl ems wi t h i nf rared thermomet ry. Poor penetrat ion,
i mproper ai mi ng, and obst ruct ions such as curvatures of the ear canal can resul t in
si gni f icant l y l ower t emperat ures. Measurements are intermi t tent . Thi s devi ce i s
generall y not usef ul f or moni t oring i n the operati ng room.
Mercury-glass
These thermometers are not usef ul f or intraoperati ve anesthesi a, as t hey have a
l ong equi l i brati on peri od (usual l y 3 t o 5 mi nut es) and cannot be read wi thout being
removed f rom t he moni tori ng si te. In the future, t hey wi l l be banned to reduce
mercury cont ami nat i on i n the envi ronment.
I f a new thermometer i s used on each pati ent , t here is a waste-di sposal problem. If
t he thermometer i s reused, i t must be cleaned and steri li zed. If a thermomet er i s
broken, t he mercury vapori zes and can present a heal th hazard.
Thermal Compartments
Al though arbi trary, i t is somewhat useful to di vi de the body i nto t wo thermal
compart ments: the core that i ncl udes the deep, vit al i nt ernal organs and a shell of
peri pheral t i ssue t hat serves as i nsul at i on for the core.
Core
Core temperature is unif orm and hi gh compared wi th t he rest of t he body. I t
normal l y vari es between 35. 7C and 37.8C (21,22,23). When signi f i cant changes
i n body heat are expected, core t emperatures shoul d be moni t ored.
Si tes dif f er in how wel l they ref lect core t emperat ure. The di ff erence may depend
on the rat e of t emperat ure change. A si te t hat ref lects core t emperat ure accuratel y
when t emperature change is sl ow may f ai l to ref l ect rapid changes.
Periphery
Normal l y, thermoregul atory vasoconst ri ct ion mai ntai ns a temperature gradi ent
bet ween t he core and peri phery (shel l ) of 2C t o 4C. Regi onal temperature
vari ati ons exi st i n the peri phery. The correlati on bet ween temperat ures measured
at di f ferent body si tes depends on several factors, i ncluding t he stabi l i t y of t he
body temperature and whether or not there have been recent col d or warm
chal l enges. Ski n and axi l lary temperatures are usuall y consi dered shel l
t emperat ures.
Monitoring Sites
Body temperature can be moni tored at a number of si tes. The temperature can vary
consi derabl y in di f f erent parts of the body at any t i me. Factors i nf l uenci ng
t emperat ure at any gi ven si t e i ncl ude the t issue' s heat producti on, the t emperature
and rate of bl ood f low t hrough the area, the amount of i nsul at i on f rom t he
envi ronment, and external i nf l uences on the si te (24).
The best si t e for t emperat ure moni tori ng depends on the purpose of the
measurement , durati on of the surgical procedure, the surgi cal si te, t he anesthesi a
t echni que, and avai l abl e equi pment . Consi derat ions should i ncl ude accuracy,
speed, conveni ence, access, saf et y, pati ent acceptabi li ty, and cost -ef fectiveness.
Absol ute accuracy i s usuall y not necessary, but measurements must be close
enough to detect t emperature changes that may i nfl uence t reatment deci si ons. I t
may be helpful to moni t or two si tes. The di ff erence between core and a second si te
can provide i ndi rect i nf ormati on on bl ood f low (sl ow change = poor bl ood f l ow) and
i s hel pf ul i n guarding agai nst an overshoot duri ng warmi ng or cool i ng.
St udi es compari ng temperature measurement among di ff erent si t es are of t en
confusi ng. Many t ry t o relate peri pheral si tes to core t emperature and use di ff erent
si tes as the standard for core temperature.
Pulmonary Artery
Pul monary artery t emperature can be measured i n pat ients who have a Swan-Ganz
catheter wi t h a t hermi stor i n pl ace. I t is thought by many to be t he best method of
measuri ng core body temperature (25,26).
Pul monary artery t emperature general l y correl ates wel l wi t h i nt rathecal and j ugul ar
bul b temperatures, even wi t h rapi d cool ing and rewarmi ng (27,28). Poor correl ati on
wi th brai n temperature was f ound duri ng prof ound hypothermi a (29).
Pul monary artery readi ngs are not rel i abl e duri ng t horacotomy or cardi opul monary
bypass when there i s no f l ow through the heart and lungs and may be di rectl y
af fected by the cardiopl egi a used duri ng cool i ng.
Esophagus
Esophageal temperature measurement can be accompl i shed by usi ng a si mple
probe, an esophageal st ethoscope wi t h t hermi stor (Fi g. 29.4), or a gast ri c tube wi t h
t he temperature sensor some distance f rom the end of t he tube (Fi g. 29.5).
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View Figure

Figure 29.4 Esophageal stethoscope and temperature probe.

Temperatures i n the esophagus may vary up t o 4C, depending on the temperat ure
probe l ocat i on wi t hi n the esophagus (7). The esophageal t emperat ure should be
measured wi t h the sensor l ocated in the l ower t hi rd or f ourth of the esophagus (30).
At t hi s dept h, the esophagus l i es between the heart and t he descendi ng aort a.
Pl aci ng t he sensor i n thi s posi t i on wi l l mi ni mi ze (but not completel y el imi nat e) t he
ef fect of respi red gases (31). When the sensor is part of an esophageal
stet hoscope, the i deal depth of placement is 12 to 16 cm distal to the poi nt of
maxi mum heart sounds (32). I f the probe i s pl aced higher i n the esophagus, the
readi ng wi l l be lower (30,32,33,34). If the probe i s placed i n the stomach, i t may
record temperatures hi gher than core, refl ecti ng l iver metabol i sm. In addi ti on, t he
response ti me to temperature changes is slow wi th t he probe i n t he stomach.
The probe i s most accuratel y pl aced by using an el ect rocardiographi c lead bui l t i nt o
t he probe (35,36). The posi tive l ead i s at tached to the probe, and t he negati ve l ead
i s attached to the ri ght shoulder. A bi phasi c P wave indicat es that the probe ti p is
at t he mi dat ri al l evel .
I n adul ts, the i deal posi t i on is approxi mately 38 to 42 cm bel ow the central i ncisors
(32) or at least 24 cm below t he l arynx (30). For nasal i nsert i on, the f ol l owi ng
f ormul as can be used (37):
L (cm) = 0.228 (standi ng hei ght) - 0.194
or
L (cm) = 0.479 (si tt i ng hei ght ) - 4. 44
where L is the lengt h f rom t he openi ng to t he nares.

View Figure

Figure 29.5 Gastric tube with temperature probe. This also
functions as an esophageal stethoscope.

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I n chi ldren, the i deal di stance i n cent i meters below t he corni cul ate carti lages i s
approxi mated by the f oll owi ng f ormula (38):
10 + (2 age i n years)/3 cm
A temperature probe can be i nsert ed i nto t he esophagus through the drai n tube of a
ProSeal laryngeal mask. The opt imal locat ion for t he t emperature probe i s 15 to 20
cm di st al t o the drai n tube (39).
Esophageal temperature i s consi dered core temperature by many i nvesti gators.
Temperatures measured in t hi s l ocati on have shown good agreement wi th
pul monary art ery t emperature (28, 40,41,42,43,44,45). Duri ng rapid warmi ng or
cool i ng, esophageal t emperature shows l ess l ag ti me than that measured at most
ot her si t es (46), al though some studies f ound that bl adder temperature showed a
cl oser approximat i on to pulmonary art ery temperature than t he esophageal
t emperat ure (47,48). Brain temperat ure may be adequately ref lected by esophageal
t emperat ure duri ng mi l d, but not profound, hypothermi a (29).
Pat i ents havi ng acti ve or passive ai rway humi di f i cat i on have sli ght l y higher
esophageal temperatures (31,34).
Contrai ndi cat ions to use of an esophageal probe i ncl ude procedures on t he f ace,
oral cavi ty, nose, ai rway, or esophagus and pati ents who have esophageal
di sorders. I t i s poorl y tol erated by awake pati ents. Correct placement may be
di ff i cul t, and probes may become di spl aced. Esophageal temperatures are
unrel i abl e duri ng thoraci c surgery. Conti nuous gastric suct ioni ng wi l l cause a
decrease i n esophageal temperature (49). When an esophageal probe i s used wi t h
t he pat ient i n the si t ti ng or prone posi ti on, oral secret i ons can t rack down t o the
connecti on bet ween t he probe and moni tor cabl e. Thi s can l ead t o i ncorrect
readi ngs (9).
Nasopharynx
The t emperature of the nasopharynx i s measured wi th a sensor that is i n contact
wi th t he posteri or nasopharyngeal wal l posteri or to the sof t pal ate. Thi s l ocati on
shoul d place i t close to the hypothal amus.
Al though some studies show a good correl at i on of nasopharyngeal temperature wi t h
core temperature (29,46, 50,51,52), ot her studi es have f ound the correlat i on less
sati sf actory (53,54,55).
An advantage of thi s si te i s that i s i t usual l y easi l y accessi bl e duri ng surgery.
Readings taken wi th a probe i n t hi s posi ti on are normal l y not af fected by the
t emperat ure of inspi red gases unless there i s a l eak around the t racheal tube
(53,56).
Thi s si te i s not usef ul f or pati ents who are awake. Epi staxi s may foll ow probe
i nsert i on (57). Nasopharyngeal temperat ure i s not af fected by conti nuous
sucti oning through a gastric tube (49).
Urinary Bladder
Uri nary bl adder t emperature moni tori ng i nvolves inserti ng an i ndwel l ing uri nary
catheter wi t h a t hermi stor or t hermocoupl e near t he pat ient end (Fi g. 29.6).
Uri nary bl adder t emperature usual l y correl at es wel l wi th t hose measured by
nasopharyngeal , pul monary art ery, and esophageal sensors
(20,28,45, 47, 48,51,58, 59,60)
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but may lag behi nd during rapid warmi ng or cool i ng (29,43,46,50,61, 62). The
correlati on wi l l be increased wi th a hi gh rate of uri ne f l ow.

View Figure

Figure 29.6 Urinary catheter with temperature sensor near
the patient end.

Uri nary bl adder t emperature moni tori ng can be used both duri ng and af t er surgery.
I t may be especi al l y usef ul i n the pati ent wi t h extensi ve burns (63). I t should not be
used duri ng geni touri nary procedures (64).
Rectum
El ect roni c rect al t hermomet ers may have t wo measurement modes: dwel l or
moni tor. In the dwel l mode, the temperature i s di spl ayed conti nuousl y. The dwel l
mode requi res a mi ni mum of 2 to 3 mi nut es to reach a stabl e temperature. The
predi ct ive mode est i mates t he temperat ure on the basis of the curve of temperature
ri se. Thi s mode requi res onl y 30 seconds. A comparison of t he measurements of
t he two modes yi elded si mi l ar val ues during steady-stat e condi t ions and mi l d
t emperat ure f l ux.
Di sposabl e probe covers can be used t o avoid cross cont aminat ion. Probes shoul d
be i nsert ed to at l east 8 cm in adul ts and 3 cm in chi l dren (65). The depth of
i nsert i on can be marked on the probe. I t shoul d be checked for pl acement af ter the
pati ent i s moved. The probe shoul d be securel y t aped to the pati ent' s but tocks, and
t he l ead wi re should be secured to a garment or sheet t o avoi d probe di spl acement .
Rectal temperature is i nf luenced by heat -produci ng f l ora, t he temperature of the
bl ood returning f rom the legs, and i nsul ati on by f eces. Rectal temperature i s
usual l y somewhat hi gher t han that measured at more central si t es duri ng steady-
stat e condi t ions (51,66,67,68,69, 70,71). The rectum i s not a vascular area, and the
l ag ti me may be prolonged wi th shif t ing temperat ure (26,52, 55,72,73).
The rectum is usual ly accessi bl e and moni tori ng relat i vel y noni nvasi ve. Rectal
t emperat ure i s not i nf luenced by ambi ent t emperature. I t is general l y di sl i ked by
pati ents as uncomf ort abl e, by hospi tal personnel as cumbersome, and by both as
aestheti call y obj ecti onabl e. Probes are prone to ext rusi on during recovery f rom
anesthesi a. Ot her disadvantages are the rel at ive i naccessi bi l i ty duri ng surgery and
t he ri sk of bacteri al contami nat ion. Contrai ndi cat ions i ncl ude gynecol ogic and
urol ogi c procedures. Bowel perforat i on is a ri sk (74). A pararectal abscess and
pneumoperi toneum have been reported wi t h i t s use (75,76).
Tympanic Membrane
Two di f ferent t echnol ogi es ut i l i ze t he ear. One uses a probe t hat cont acts the
t ympanic membrane, and the other measures inf rared radi at i on.
Contact
The anat omical posi ti on of the tympani c membrane i s deep wi thi n the skul l and
separated f rom the i nternal caroti d artery by onl y t he narrow ai r-f i l l ed cl ef t of the
mi ddl e ear and a t hi n shel l of bone, maki ng i t an att ract ive si t e for temperature
measurements. The t ympani c membrane and the hypothal amus share a common
bl ood suppl y, so measuri ng temperature at t hi s si te may refl ect thermal i nf ormati on
at t he primary si te of thermoregul ati on (17).
Temperature can be measured by i nserti ng a thermi stor or thermocoupl e probe into
t he external audi tory canal unti l i t contacts t he tympani c membrane. Because of t he
danger of perforat ing the membrane, cl i nicians tend not t o place the probe far
enough i nto t he canal . If i t does not touch the membrane, t he readi ngs wi l l not be
accurate. In t he awake pat ient, i t shoul d be i nserted unti l t he pat i ent f eel s the
t hermocoupl e touch t he t ympanic membrane; appropri ate pl acement is conf i rmed
when t he pat i ent easi l y detects a gentl e rubbi ng of t he at tached wi re (77). The
l ower anteri or quart er of the membrane shoul d be used (78). Af ter the probe i s
i nsert ed, t he aural canal shoul d be occl uded wi th cott on wool and covered
external l y to prevent ai r movement f rom cool i ng t he probe (79,80).
Contact tympani c membrane probes are shown i n Fi gure 29. 7. The sensor i s
enclosed i n sof t foam. It usual l y has a wi dened segment, piece of f oam, or a
f eather or barb t o hol d i t i n pl ace af t er i nserti on. Af ter i nsert i on, the readi ng should
stabi l ize qui ckl y. I f i t does not, the probe shoul d be sl owl y advanced unti l the
readi ng stabi l i zes.
Numerous studies have shown a good correl ati on between tympani c membrane
t emperat ure and t emperature measured i n the esophagus, pul monary artery, or
uri nary bl adder (31, 71,78,79, 80,81,82,83,84,85). Temperat ure may be l ess
accurate duri ng rapi d changes (29,40,79).
Head posi ti on can cause asymmet ri c changes i n the t ympani c temperatures (86).
Upon assumi ng a l ateral posi t ion, the t emperature on the l ower si de increases
whi l e t hat on the upper si de decreases.
Advantages of tympani c membrane temperat ure moni tori ng i ncl ude cleanl i ness and
conveni ence. I t i s tol erat ed by consci ous pati ents, maki ng i t usef ul f or
postoperati ve moni tori ng. The si te i s readi l y accessi bl e duri ng most surgi cal
procedures.
Compl i cat i ons have been reported. Oozing f rom t he ear, trauma t o the external
audi tory canal wi th subsequent external ot i ti s, and perf orat ion of the membrane
have been report ed (81,87,88). These compl i cati ons occurred bef ore t he advent of
f lexible cott on-ti pped probes that are less traumati c (7). Recommended methods to
avoid t rauma include ot oscopi c i nspecti on of t he canal and drum bef ore i nsert i on,
stoppi ng i nsert i on as soon as resi stance is f el t, and pl acement in awake pat i ents to
assess discomf ort . Care should be taken that the
P. 865

probe i s not pushed i nto the canal when the head i s moved.

View Figure

Figure 29.7 Tympanic membrane temperature probes.

Contrai ndi cat ions incl ude any ear abnormal i ty t hat woul d prevent correct
pl acement , a skull f ract ure t hat passes through the osseous meat us, and
perf orati on of t he tympani c membrane.

View Figure

Figure 29.8 Disposable probe for measuring skin
temperature.

Infrared
I nf rared ear t hermomet ry (i nf rared emissi on detect ion t hermomet ry, i nf rared
t ympanic membrane thermomet ry, i nf rared tympani c thermomet ry) i s perf ormed by
i nsert i ng an otoscopeli ke probe i nt o the external ear canal (19). The t i p i s usual l y
covered by a di sposabl e cover. The devi ce detects the amount of i nf rared heat
emi tt ed. The wi de angl e is t oo l arge t o measure onl y t he tympani c membrane, so i t
al so reads the temperature of t he ear canal .
Si nce t hese t hermometers are known to gi ve t emperatures l ower than core
t emperat ures, some manuf acturers provi de of fsets to est i mate t he temperature at
ot her si t es (89). These off sets vary for di ff erent brands (17,26,90,91).
A tug on the ear to st raighten the canal whi l e taki ng a readi ng was f ound by some
i nvesti gat ors to i mprove correlat i on wi t h core temperatures (92,93, 94, 95,96). Ot her
studi es di d not f i nd that an ear tug i s hel pf ul (20,69). The devi ce shoul d be i nsert ed
wi th a gentl e back and fort h moti on, and f i rm but gent le pressure should be appl i ed
t o seal the canal f rom ambient ai r (94).
Many studies have compared temperatures obtai ned by i nf rared ear thermometers
t o t emperatures obt ai ned f rom ot her si tes
(19,25,41, 42, 44,52,58, 66,69,70,83,90,91,93,97,98, 99,100,101,102,103,104,105,106
, 107,108,109,110,111,112,113,114,115,116, 117,118,119,120,121,122,123). The
correlati ons vary f rom excel l ent to poor. There is consi derable vari at ion among
di ff erent i nstruments and wi th di f f erent users of t he same i nst rument
(20,109,114,120). A di f ference of 1.6C between the t wo ears has been reported
(114). Readings are aff ected by t he ambi ent t emperat ure (124,125). If t he f ace i s
cooled, there wi l l be a decrease in the readi ng (126). Acute ot i tis media wi l l not
i nf l uence the reading unl ess there i s suppurat ion, i n which
P. 866

case the reading wi l l be sl i ghtl y i ncreased (98,102,117,127).
Advantages of inf rared temperature moni tori ng incl ude speed and reduced pot ent ial
f or cross contami nati on. It i s noninvasi ve, requi res no cl othi ng removal , and is wel l
t olerat ed by conscious pat ients. The si t e i s usual l y readi l y accessi bl e. The ease
wi th whi ch t he measurements can be obtai ned has made these the t hermometers of
choice in many pre- and postoperati ve uni ts. Because t he readi ngs are intermi ttent
and subj ect t o such variabil i ty, thi s t echnology i s not recommended f or
i ntraoperati ve use.
Skin
Ski n temperature can be measured by using a l iqui d crystal device or f l at disc or ti p
of a l ead containing a thermocoupl e or thermi stor (6) (Fi g. 29. 8). Some ski n probes
have a special backing to at tach to the body and materi al t o i nsul ate t he sensor
f rom ambi ent condi t ions. An opaque dressi ng and/ or t ape over t he sensor may
decrease the eff ect of envi ronmental f actors.
Ski n temperature i s most commonl y measured at t he f orehead, because thi s si te
has a f ai rl y good bl ood f l ow, and t here is not much underl ying f at . The back, chest ,
anterior abdomi nal wal l , f i ngers, toes, and the antecubi tal space insi de the el bow
have al so been used.
The correl at ion between ski n temperature and core temperature i s cont roversi al .
Ski n surf ace temperature i s typical l y 2C to 4C l ess t han core temperature. Some
manuf acturers bui l d i n an of fset to compensat e f or t hi s di ff erence (128). I n some
studi es, ski n temperature has been found to correl ate wel l wi t h core temperature
(129, 130). However, most invest i gati ons have f ound t hat ski n temperature does not
accuratel y ref l ect core temperature, and there may not be a rel at i onshi p bet ween a
change i n ski n and core temperature (29,31, 61,78, 108, 131,132, 133).
Moni tori ng ski n temperature carri es f ew ri sks. The si te is easi l y accessi bl e. The
mai n di sadvantage i s that ski n temperature i s a poor esti mate of core body
t emperat ure and may give erroneous informat ion (16). Ski n temperature readi ngs
are aff ected by ambi ent t emperat ure, ski n surface warmi ng devi ces, i nt raoperat i ve
changes i n cardi ac output, and regi onal vasoconst ri cti on (134,135, 136, 137). The
useful ness of ski n temperat ure moni tori ng as a screeni ng devi ce for mal i gnant
hyperthermi a i s l imi ted, as cutaneous vasoconstricti on may occur wi th t hi s
syndrome (138).
Ski n temperature may be used to eval uate the qual i t y of a regional bl ock. A ri se i n
ski n temperature i s an indi cati on that the bl ock is successf ul . Anot her use is i n
mi crosurgery. An i ncrease i n ski n temperature may i ndi cate that bl ood f low t o that
area has i ncreased.
Axilla
To measure axi l l ary temperat ure, a mercury-gl ass thermometer or a probe wi t h a
t hermocoupl e or thermi stor i s posi ti oned over the axil l ary art ery and t he arm
adducted (31). Si gnif i cant dif f erences have been f ound bet ween mercury and
el ect roni c axi l l ary temperatures (68, 111). Temperature should not be measured on
t he same si de where a bl ood pressure cuf f i s on the upper arm. Equi li brati on may
t ake as l ong as 10 t o 15 minutes (72,138).
Al though a f ew studies f ound sat isfactory correl ati on wi th more cent ral si tes
(133, 139,140,141, 142), most studi es show poor correl ati on
(20,25,29, 45, 51,58,68, 69,98,115,116, 129, 143,144,145,146,147, 148, 149).
Axi l lary t emperature measurements are easy t o t ake and are not obj ecti onable t o
t he pat ient or nursi ng staf f . The si te i s usual l y accessible. However, i t i s not
consi dered accurate or rel i abl e i n adul ts. I t i s used most f requent l y on i nf ants and
chil dren because t he pati ent' s smal l si ze and greater surface vascul ature make a
rel ativel y uni f orm temperature (17,31). Readi ngs are i nf l uenced by cont act wi t h the
probe, ski n perfusion, exposure t o the envi ronment, ski n warmi ng devi ces, and
proxi mi t y of t he probe to t he axi l l ary artery (20,26,56, 148).
Mouth
Subl i ngual temperat ure i s measured by placi ng a probe i n one of the pockets on
ei ther si de of the f renul um of the tongue (151). The pat ient' s mouth shoul d be
cl osed and enough ti me al l owed for the reading to be accurate. Thi s area contai ns
smal l muscul ar art eri es that respond to masti cati on or hot or cold l iqui ds by
expanding or cont racti ng.
Correlat i on wi t h temperatures measured at more cent ral si tes varies somewhat but
i n general i s fai rl y sat isf actory (20,58,77,113, 115,151,152, 153).
Subl i ngual temperat ures are wel l t ol erated by pati ents. Readi ngs are not aff ected
by t he presence or absence of teeth, i ntubat i on, admi ni st rat i on of oxygen, a
nasogastri c t ube on cont i nuous suct ion, or t he temperature of i nspi red gases
(145, 150,154). Subl ingual temperature may be i naccurate i f the pati ent is a mouth
breat her or has t achypnea (155). Warm and col d ambi ent temperatures have a
smal l eff ect on oral temperatures (124,125).
Trachea
Temperatures i n the t rachea can be measured by using a t racheal tube wi t h the
t emperat ure sensor i n the cuf f . Studies dif fer i n how wel l t emperatures measured at
t his si te correl at e wi t h those at other si tes (156,157,158,159).
P. 867


Inguinal Area
The i nguinal area has been used to measure t emperature (45,72,160). The l eg i s
f i rst abduct ed and the f emoral pul se determi ned. The sensor i s pl aced j ust l ateral
t o t he f emoral artery, and the l eg i s adducted to create a seal . A si gni f i cant
drawback to t hi s si te is t he t ime requi red to reach equi l i bri um.
Hypopharynx
A thermocoupl e can be att ached to t he cuf f of a supragl ott i c devi ce t o measure
t emperat ure i n the hypopharynx (161,162). Temperatures measured in t hi s l ocati on
have correl at ed wel l wi th t hose at other si tes.
Hazards of Thermometry
Damage to the Monitoring Site
Tympani c membrane and rectal perf orati on and t rauma to t he nose, ext ernal
audi tory canal , rectum, and esophagus have been report ed
(74,75,76, 81, 87,88,163,164). Probes can have sharp edges that coul d present a
hazard t o the pati ent (165).
Burns
Burns can occur at the measurement si te i f t he probe acts as a ground for the
el ect rosurgi cal apparat us (166, 167, 168). No i nsulati on can compl etel y bl ock radio
f requency currents, and i f there i s no other sati sf actory ret urn path, the current can
burn through i nsul ati on (169). Usi ng a batt ery-operated devi ce i s no guarantee of
el ect rical saf et y, because the chassis may be grounded t hrough a metal support.
Temperature probes shoul d be exami ned before use to detect damage t o the
i nsul at i on. Esophageal burns may be avoided by inserti ng the probe via a smal l
t racheal tube (170). The probe may be pul l ed back i nto the tube duri ng peri ods of
maxi mal electri cal act ivi t y.
Incorrect Information
A f aul t y probe can cause an i ncorrect t emperature to be di spl ayed
(171, 172,173,174). Secret ions or f luids i n the connecti on between the probe and
readi ng i nst rument can resul t i n f alsel y elevat ed readi ngs (9,10). If t he bat tery i n a
bat tery-powered devi ce i s depl et ed, t he uni t may stop f uncti oni ng or give i ncorrect
i nformati on (6). Usi ng j acks that f i t the recept acl e but have i nt ernal el ect roni cs
i ncompati bl e wi t h the moni tor can gi ve false readings.
Probe Contamination
Reusabl e temperature probes may be a source of bacteri al or vi ral pathogens even
i f protecti ve covers are used (6,175).
Faulty Probes
Af ter a probe i s removed f rom i ts packaging, i t shoul d be i nspected. A part of the
sheath on a probe coul d break of f and be aspi rated.
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P. 870


Questions
For the f ol lowing quest ions, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i f D i s correct
i f A, B, C, and D are correct .
1. Advantages of thermistors include
A. Smal l si ze
B. I nterchangeabl e and di sposable probes
C. Conti nuous readi ngs
D. Rapid response ti me
Vi ew Answer2. Wi th the plati num wi re thermometer
A. Current f lows i n proport i on t o the temperat ure dif ference
B. Rapid t hermal equi l i brati on i s possible because of the smal l di amet er of the wi re
C. Two wi res of di ff erent metal s are wel ded together at thei r ends
D. Resistance of t he wi re vari es wi th temperature
Vi ew Answer3. Advantages of the l iquid crystal thermometers include
A. Fast cont inuous readi ngs
B. I nf rared l amps do not interfere wi th t hei r readi ngs
C. They can be appl i ed pri or t o i nduct ion
D. Accuracy even at the ext remes of ambi ent temperature
Vi ew Answer4. Advantages of infrared temperature moni tors i nclude
A. They do not cont act the eardrum di rectl y
B. Tolerated wel l by pati ents
C. Rapid measurement
D. Conti nuous measurement
Vi ew Answer5. The accuracy of axi ll ary temperature determi nati ons is
i nfl uenced by
A. Proxi mi ty to the axi l l ary art ery
B. Perf usi on of t he skin
C. Ski n contact wi th t he probe
D. Pati ent age
Vi ew Answer6. Factors infl uencing the temperature reading i n the naso-
pharynx i ncl ude
A. Temperature of the i nspi red gases
B. Leak i n t he t racheal tube cuf f
C. Gastric suct ion
D. Temperature i n the hypot hal amus
Vi ew Answer7. For correct use of the esophageal temperature monitor,
A. The sensor shoul d be locat ed in t he lower t hi rd to l ower f ourth of the esophagus
B. St omach placement of the probe wi l l provide t emperat ures lower t han core
C. The probe shoul d be pl aced 12 to 16 cm di stal to t he point of maxi mum heart
sounds
D. Temperature of t he respi red gases i s not a f actor i n the l ower thi rd of the
esophagus
Vi ew Answer8. Factors that can cause esophageal temperatures to be
unrel iable i ncl ude
A. Ai rway humi di f i cat i on
B. Thoraci c surgery
C. Conti nuous gastric suct ion
D. Pati ent i n the si t t ing posi ti on
Vi ew Answer9. When using the tympani c membrane to measure
temperature,
A. The probe does not have to actual l y contact the membrane
B. Perf orati on of t he membrane can occur
C. Readi ngs wi l l be stabl e i f t he probe i s i n cl ose proxi mi ty to the membrane
D. The probe shoul d have a means to hol d i t i n pl ace
Vi ew Answer10. Factors that wi l l cause i ncorrect readi ngs from an
i nfrared ear thermometer i ncl ude
A. Cerumen
B. Ambient ai r temperature
C. Ot i t i s medi a wi t h suppurat i on
D. Ot i t i s medi a wi t hout suppurati on
Vi ew Answer11. Factors affecting the temperature measured in the
rectum i ncl ude
A. Cystoscopy
B. Peri toneal lavage
C. Rectal contents
D. Col on pathology
Vi ew Answer