Pediatr Surg Int (2006) 22: 182–185
DOI 10.1007/s00383-005-1618-z
O R I GI N A L A R T IC L E
Michael R. J. Sury Æ Stephen Scuplak
Water-filled garment warming of infants undergoing open abdominal
or thoracic surgery
Accepted: 15 November 2005 / Published online: 22 December 2005
Ó Springer-Verlag 2005
Abstract We have assessed the efficacy of a water-filled
garment (ThermoWrap—AllonTM 2001) to maintain
normothermia in small infants during major open
abdominal or thoracic surgery. Twenty-two patients
were studied in a case-matched comparison of two
methods of thermal control intended to maintain core
body temperature at 37°C. The standard method
involved a warm air mattress with additional insulation.
The ThermoWrap garment covered the head, trunk and
legs and the water temperature was automatically con-
trolled. Central and peripheral temperatures were
recorded every 15 min. Nineteen infants had abdominal
and three had thoracic operations. The mean weight was
3.2 kg (range 1.4–7.8 kg). Over time, the core tempera-
ture declined with standard care but not with the
ThermoWrap. Core temperature was statistically lower
in the standard care infants by 30 min after start of
surgery. Six infants had a core temperature of less than
35°C with standard care (lowest 33.7°C); the lowest
temperature with the ThermoWrap was 35.6°C. Some
infants had cold hands with the ThermoWrap. Core
temperature is better preserved with the ThermoWrap;
extra insulation of exposed arms may be necessary. An
important advantage of the ThermoWrap is its ability to
control body temperature automatically.
Keywords Perioperative hypothermia Æ
Thermoregulation Æ Paediatric anaesthesia
Introduction
Hypothermia in infants may have detrimental effects
both during major surgery and recovery and it is stan-
dard practice to aim to maintain normothermia at all
M. R. J. Sury (&) Æ S. Scuplak
Department of Anaesthesia, Great Ormond Street Hospital
for Children NHS Trust, WC1N 3JH London, UK
E-mail: surym@gosh.nhs.uk
Tel.: +44-20-78298865
Fax: +44-20-78298866
times. During most paediatric surgery and anaesthesia,
normothermia is achieved by a combination of passive
and active methods that include simple insulation,
reflective blanket, electrical mattress, warm air mattress
or duvet [1–3], overhead radiant heating, warming of
intravenous fluids and control of ambient temperature
and airflow. Furthermore, because many major ‘‘open’’
operations have been replaced by minimal access tech-
niques, body temperature often rises so that cooling,
rather than warming, may be necessary. Nevertheless, in
small infants (less than 5 kg) undergoing major open
abdominal and thoracic surgery, we have found that our
standard warming methods are not sufficient to prevent
hypothermia. The AllonTM 2001 system is a novel sys-
tem that pumps water into a garment that covers the
trunk, head and legs (ThermoWrap) but can be un-
wrapped to expose the thorax and abdomen for surgery
[4]. The temperature of the water can be controlled
automatically to maintain a set core temperature. The
AllonTM 2001 system has been used extensively in pae-
diatric surgery but there is little data comparing its use
in small infants with other standard temperature control
methods [5]. We have therefore assessed the efficacy of
the ThermoWrap and compared it with our best stan-
dard practice.
Methods
Twenty-two infants undergoing major abdominal or
thoracic surgery were studied in a non-randomised, case-
matched, comparison of two methods of intra-operative
temperature control. The study was registered with the
local research and development department who decided
that neither ethical committee review nor parental con-
sent was necessary. On arrival in the operating depart-
ment, attempts to maintain body temperature began
before anaesthesia using a combination of overhead
heating and insulation with cotton wool blankets or
bubble wrap. Anaesthesia was induced with sevoflurane
and maintained with isoflurane in a mixture of air and

oxygen. Atracurium was used for muscle relaxation and
analgesia was achieved with fentanyl. All intravenous
fluids were warmed to 37°C. Theatre temperature was
maintained between 20 and 22°C. Central (nasopha-
ryngeal) and peripheral (palm) temperatures were re-
corded at the start of surgery and every 15 min
thereafter. During surgery one of two thermal control
methods was used.
Standard thermal care
Infants were placed upon a warm air mattress or duvet
and the head and limbs were covered with cotton wool
or bubble wrap.
ThermoWrap
A ThermoWrap garment covered the head, trunk and
legs through which water was pumped at a variable
temperature (AllonTM 2001 system) controlled to
maintain a core temperature of 37°C. No other insula-
tion was used.
Infants were first assigned to the Allon system until
others presented who could be matched for either
operation or body weight, and these were assigned to
standard thermal care. Statistical analysis was with
analysis of variance for repeated measures and t tests
where appropriate (Table 1).
Results
Of 22 infants, three had thoracotomy for repair of tra-
cheo-oesophageal fistula and all others had various open
abdominal procedures. The mean weight of all infants
was 3.2 kg; the range was 1.9–7.8 kg, and nine infants
weighed less than 2.5 kg. All operations lasted at least
45 min. All operations lasted 75 min except for three
having standard care and three having the Thermo-
Wrap. Plots of the temperature of individual patients
Table 1 Body weights and
operations Standard care
Weight (kg) Operation
1.4 Bowel resection
5 Duhammel operation
7.6 Colostomy revision
3 Gastroschisis (silo tuck)
2.4 Gastroschisis (silo tuck)
2 Bowel resection
2.7 Gastroschisis (silo tuck)
3.3 Diaphragmatic hernia repair
2.7 Repair of tracheo-oesophageal fistula 2.9
4 Ladds operation
2.3 Repair of tracheo-oesophageal fistula 1.5
183
against time confirmed that the graphs of group mean
temperature (Figs. 1, 2) were representative.
Over time, there was a trend for the mean core tem-
perature to decline with standard care whereas the
ThermoWrap tended to maintain normothermia
(Fig. 1). An analysis of variance for repeated measures
found a significant interaction for time and treatment
group (P<0.001). By 30 min core temperature was
statistically lower in the standard care group (mean
difference 1.2°C, 95% confidence interval 0.8–1.6,
P<0.001). Six infants had a core temperature of less
than 35°C with standard care (lowest 33.7oC) compared
with the ThermoWrap when the lowest temperature was
35.6°C.
Figure 2 suggests that infants with the ThermoWrap
had lower hand temperatures. Two infants had a hand
temperature of less than 34°C with standard care (lowest
30.7°C) compared with seven with the ThermoWrap
(lowest 27.7°C). There was, however, no significant
interaction found with the analysis of variance test
(P=0.3).
Discussion
In this study, in which 16 out of 22 of our infants
weighed less than 3 kg, core temperature greater than
36°C was almost always preserved with the Thermo-
Wrap. Some infants however had cold hands, because
they were outside the garment, and simple insulation
would probably have overcome this problem.
Other surgical teams have published their experience
with the Allon system in children and infants and shown
that it is effective, although they have not used it
extensively in infants under 3 kg [4, 5]. Also, only one of
these series compared the ThermoWrap with standard
care [4] and, in the other study, which had no controls,
standard warming methods may have been effective
enough [5]. In adults as well, the Allon system performs
better than warm air mattresses during surgery [6], and
is more effective at warming hypothermic anaesthetised
volunteers [7]. Hyperthermia can also be corrected
and we have observed that the ThermoWrap quickly
ThermoWrap
Weight (kg) Operation
1.4 Bowel resection
5 Colostomy
7.8 Pyeloplasty
2.2 Bowel resection
2.9 Bowel resection
2.8 Bowel resection
2.2 Gastroschisis (primary closure)
2.3 Bowel resection
Repair of tracheo-oesophageal fistula
3.1 Volvulus
Colostomy closure
184

37.5 air mattresses: first the garments are relatively more

expensive, and second the Allon pump needs 10–15 min
37 to run through its self-test and warming cycle. The
36.5 garments themselves are bulky but do not limit the
exposure required for surgery. We found that the gar-
36 ment bends easily and can be held in place close to the
temp (°C)

body contours by adhesive tape. There was no interfer-

35.5
35
34.5
standard care
34
Thermowrap
33.5
0 15 30 45
Minutes after start of surgery
Fig. 1 Mean nasopharyngeal temperature (SD) versus time
controls the temperature of a child with pyrexia under-
going emergency surgery. The automaticity of the Allon
system is useful during prolonged operations [8].
The temperature of the water within the garment is
controlled automatically by a bedside pump and can
range from 18 to 39.5°C. The water temperature de-
pends upon the set desired central temperature and the
core temperature itself; if the infant is cool (or too
warm) the water temperature will rise (or fall) in order to
achieve the set temperature. Thermal injury should not
be possible because the maximum temperature achiev-
able is less than 40°C. Pressure injury could occur, al-
though this is unlikely in infants because of low body
weight. Dermal injury has been described in an adult
during prolonged surgery [9]. To reduce the chance of
dermal pressure injury, the pump allows water to drain
from the garment for 1 min in every 15. There are two
potential disadvantages of the Allon system over warm
39
37
35
temp (° C)
ence with monitoring. The skin was dimpled by the
texture of the garment but the dimpling disappeared
quickly when the garment was removed. We found no
evidence of thermal injury.
The potential deleterious effects of hypothermia in-
clude the reduction of coagulation, cardiac output and
drug clearance, yet surprisingly there is little supportive
60 75
data to show any demonstrable harm during surgery
itself—hypothermia has been demonstrated to increase
blood loss during hip surgery [10]. There is, however,
evidence that intraoperative hypothermia has postoper-
ative effects. Recovery from anaesthesia is prolonged in
mildly hypothermic adults but not in children [11, 12].
More importantly, wound infection is increased in
adults who have been hypothermic, probably due to
reduced skin blood flow and leukocyte function [13]. The
effect of hypothermia on wound infection in infants and
children is less clear. In major cardiac surgery, the rate
of sternotomy wound infection is highest in those who
have had the lowest intraoperative temperature [14]. In
the infant, thermogenesis from brown fat metabolism
is suppressed by anaesthesia [15] and, when it restarts
during recovery, it can increase oxygen demand [1]. This
may cause acidosis or hypoxemia if oxygen supply is
inadequate.
With respect to our study design, we acknowledge the
possibility of selection bias to one or other temperature
control method and that this would be less likely with
randomisation. There were, however, practical difficul-
ties with randomisation for this assessment. In our
hospital our surgeons were using laparoscopic tech-
niques for most ‘‘cold’’ surgery and therefore the num-
ber of infants available to us was much reduced.
Randomisation would have required written consent
and, whereas this is possible, it can be difficult
for emergency surgery if parents are distressed or not
present.
We have compared one practice with another and we
believe that the care delivered in the standard care group
was a true reflection of our current best practice. The

33 Allon system is more effective than our standard meth-

ods but we do not propose that it should be used for all
31 infant surgery. Our standard methods (simple insulation
and warm air mattress) are effective enough for closed
standard care operations and the extra expense of the ThermoWrap is
29
therefore not justified.
Thermowrap
Hypothermia itself may have an advantage in organ
27 preservation if oxygen delivery is marginal and, if this is
0 15 30 45 60 75 true, it is reasonable to ask the question: what is the best
Minutes after start of surgery core temperature? To answer this, the Allon system may
be a useful research tool since it can control the core
Fig. 2 Mean hand temperature (SD) versus time temperature effectively and automatically.

Acknowledgements We are grateful to Eschmann Holdings Ltd
(West Sussex BN15 8TJ, UK) and to MTRE Advanced Technol-
ogies Ltd (Israel) for providing the Allon equipment and disposable
garments. Dr. Deborah Ridout of the Institute of Child Health
London provided statistical advice. Dr. Sury is supported by grants
from the Portex Department (Institute of Child Health) and Great
Ormond Street Hospital for Children NHS Trust.
References
1. Nilsson K (1991) Maintenance and monitoring of body tem-
perature in infants and children. Paediatr Anaesth 1:13–20
2. Bissonnette B (1992) Temperature monitoring in pediatric
anesthesia. Int Anesthesiol Clin 30:63–76
3. Kurz A, Kurz M, Poeschl G et al (1993) Forced-air warming
maintains intraoperative normothermia better than circulating-
water mattresses. Anesth Analg 77:89–95
4. Katz J (2002) Novel feedback controlled circular water system
(Allon 2001) is superior to forced warmed air device in main-
taining normothermia in infants undergoing major surgery.
Anesthesiol ASA Abstr
5. Nesher N, Wolf T, Uretzky G et al (2001) A novel thermo-
regulatory system maintains perioperative normothermia in
children undergoing elective surgery. Paediatr Anaesth 11:555–
560
6. Janicki PK, Higgins MS, Janssen J et al (2001) Comparison of
two different temperature maintenance strategies during open
abdominal surgery: upper body forced-air warming versus
whole body water garment. Anesthesiology 95:868–874
185
7. Taguchi A, Ratnaraj J, Kabon B et al (2004) Effects of a cir-
culating-water garment and forced-air warming on body heat
content and core temperature. Anesthesiology 100:1058–1064
8. Janicki PK, Stoica C, Chapman WC et al (2002) Water
warming garment versus forced air warming system in pre-
vention of intraoperative hypothermia during liver transplan-
tation: a randomised controlled trial. BMC Anesthesiol 2:7
9. Gali B, Findley JY, Plevak DJ (2003) Skin injury with the use
of a water warming device. Anesthesiology 98:1509–1510
10. Schmied H, Kurz A, Sessler DI et al (1996) Mild hypothermia
increases blood loss and transfusion requirements during total
hip arthroplasty. Lancet 347:289–292
11. Bissonnette B, Sessler DI (1993) Mild hypothermia does not
impair postanesthetic recovery in infants and children. Anesth
Analg 76:168–172
12. Lenhardt R, Marker E, Goll V et al (1997) Mild intraoperative
hypothermia prolongs postanesthetic recovery. Anesthesiology
87:1318–1323
13. Kurz A, Sessler DI, Lenhardt R (1996) Perioperative normo-
thermia to reduce the incidence of surgical-wound infection and
shorten hospitalisation. Study of wound infection and tem-
perature group. N Engl J Med 334:1209–1215
14. McAnally HB, Cutter GR, Ruttenber AJ et al (2001) Hypo-
thermia as a risk factor for pediatric cardiothoracic surgical site
infection. Pediatr Infect Dis J 20:459–62
15. Lindahl SGE, Grigsby EJ, Meyer DM, Beynen FMK (1992)
Thermogenetic response to mild hypothermia in anaesthetized
infants and children. Paediatr Anaesth 2:23–9