ADDIS ABABA UNIVERSITY

MAGNITUDE OF INTERAOPERATIVE AND POSTOPERATIVE

HYPOTHERMIA AND ASSOCIATED FACTORS, AMONG PEDIATRIC
PATIENTS THAT WERE OPERATED IN TIKUR ANBESSA SPECIALIZED
HOSPITAL

Principal Investigator: MulatMossie (BSc, MSc student)

Mail:[email protected]

Telephone: 0910469914

Name of advisor: Mr.WesenyelehAdmassu (BSc, MSc)

A RESEARCH PAPER SUBMITTED TO SCHCOOL OF MEDICINE, DEPARTMENT OF ANESTHESIA IN

ADDIS ABABA UNIVERSITY, IN FULFILLMENT OF THE REQUIREMENT FOR THE MASTER DEGREE
IN ANAESTHESIA.

Addis Ababa, Ethiopia, 2016 G.C

ABSTRACT

BACKGROUND: -Humans maintain constant body temperature within a wide range of changes
in external environment. Perioperative hypothermia is one of the major problems during surgery
that can affect operated pediatric patients.

OBJECTIVE: - The objective of this study was to determine magnitude of intraoperative and
postoperative hypothermia and determinant factors among pediatric patients operated in Tikur
Anbessa Specialized Hospital from January to February, 2016.

METHODS: - Study was conducted with Cross sectional study design. All selected elective
surgical pediatric patients, between 1 January 2016 and 30 March2016 were eligible to the study.

Data was entered into Epi info version 7 and exported to SPSS version 20 for analysis. Binary
Logistic regression was used to test each factor with the dependent variable, and variables with P
value of <0.2 were carried to multi variant analysis. 95% C.I. and P value of <0.05 was used as a
cutoff point to test for significance of associations.

RESULTS: -A total number of 90 pediatric patients were enrolled to the study of whom 26
females and 64 males. The ages of patients varied from 26 days to 14 years (mean 5.63 ±4.40).
Hypothermia incidence was calculated after induction, an hour and two hours of induction was
72.2%, 64.4%, 83.8% respectively. After third hours there were three cases but all had been
hypothermic. And postoperative incidence of hypothermia was 78.9% of all pediatric patients.

Conclusion: -Intraoperative and Postoperative hypothermia is a common problem in this

Hospital. Therefore, we suggest that temperature monitoring, patient warming and OR
temperature managing should be a routine procedure during anesthesia management and PACU.

I
ACKNOWLEDGMENT:

I would like My gratitude to Addis Ababa University that provides me to conduct the research
and financial support.

I would like to express my deepest gratitude to Dr. Andrew (UK pediatric Anesthesiologist) and
Ph. Elizabeth (USA prophesier of pediatric and anesthesiology) who brought tympanic
thermometers.

I would like to express my appreciation to my advisors Mr.Wesenyeleh (BSc, MSc) who helped
me from the start of this thesis and provides me very impressive advice and support to do this
paper.

The last, but not the least I would like to thank all the researchers who provided online articles
which were used for literature review.

II
Contents Pages

I. SUMMARY……………………………………………………………………I
II. ACKNOWLEDGEMENT…………………………………………….………II
III. CONTENTS…………………………………………………………….…… III
IV. List of tables…………………………………………………………………. V
V. List of figures………………………………………………………………… V
VI. ACRONYMS…………………………………………………………………. VI
CHAPTER ONE
1. INTRODUCTION
1.1 BACKGROUND……………………………………………………………1
1.2 STATEMENT OF THE PROBLEM………………………………………...3
1.3 JUSTIFICATION OF THE STUDY…………………………………………4
CHAPTER TWO
2. LITERATURE REVIEW……………………………………………………………5
2.1 MONITORING OF TEMPERATURE………………………………………5
2.2 MONITORING SITES………………………………………………….……5
2.3 INCIDENCE OF HYPOTERMIA……………………………………………6
2.4 RISK FACTORS FOR PERIOPERATIVE HYPOTHERMIA………………7

CHAPTER THREE

3. OBJECTIVE…………………………………………………………………………9
3.1 GENERAL OBJECTIVE…………………………………………………….9
3.2 SPECIFIC OBJECTIVES……………………………………………………9

CHAPTER FOUR

4. METHODOLOGY……………………………………………….…………….….10
4.1 STUDY AREA AND PERIOD……………………………………………10
4.2 STUDY DESIGN……………………………………………………….…10
4.3 SOURCE POPULATION…………………………………………………10
4.4 STUDY POPULATION……………………………………………………10
4.5 EXCLUSION CRITERIA……………………………………………….….10

III
 4.6 SAMPLING AND SAMPLE SIZE DETERMINATION……………….….11
4.7 VARIABLES OF THE STUDY……………………………………….……11
4.7.1 DEPENDENT VARIABLE…………………………………......11
4.7.2 INDEPENDENT VARIABLES…………………………………11
4.8 DATA COLLECTION TOOLS………………………………………….......11
4.8.1 QUESTIONERS………………………………………………….11
4.8.2 BODY TEMPRATURE MEASURMENT……………………….11
4.9 DATA ANALYSIS PROCEDURE……………………………………….….12
4.9.1 DATA ENTRY AND ANALYSIS……………………….………12
4.10 DATA QUALITY CONTROL……………………………………………12
4.11 ETHICAL CONSIDERATION …………………………………………...12
4.12 OPERATIONAL DEFINITIONS ………………………………………...12

CHAPTER FIVE

5. RESULTS…………………………………………………………………………….14
CHAPTER SIX
6. DICUSSION……………………………………………………………………….….23
CHAPTER SEVEN

CHAPTER SEVEN:

7. Conclusion and RECCOMENDATION……………………………………….….25

7.1 Conclusion.......................................................................................25
7.2 RECCOMENDATION……………………………………………...…...……25
8. REFERENCES………………………………………………………………………...26
9. ASSURANCE OF PRINCIPAL INVESTIGATOR……………………………………....…...31
10. ANNEXES……………………………………………………………...………………32
10.1 QUESTIONNAIRE…………………………………………………………...32
10.2 INFORMATION SHEET AND CONSENT FORM………………………….36
10.2.1 STUDY SUBJECTS CONSENT FORM……………………….…37

IV
List of tables pages

Table: - 1Personal and socio-demographic characteristics pediatric surgical patients at Tikur

Anbessa Specialized Hospital January-March 2016 G.C……………………………………….15

Table: - 2 Shows Preoperative clinical condition of the respondents or pediatric patients who
underwent surgery in Black lion specialized hospital from January-March 2016 G.C…………16

Table: -3 Illustrate Intraoperative events for respondents or pediatric patients who underwent
surgery in Black lion specialized hospital from January-March 2016 G.C…………….……….17

Table: - 4 The association of variables to intraoperative hypothermia for pediatric patients who
underwent surgery in Black lion specialized hospital from January-March 2016 G.C…….……21

Table: - 5 Illustrate the association of variables to postoperative hypothermia for pediatric

patients who underwent surgery in Black lion specialized hospital from January-March 2016
G.C……………………………………………………………………………………………….22

List of figures pages

Figure: - 1 Distribution of average intraoperative body temperature for pediatric patients who
underwent surgery in Black lion specialized hospital from January-March 2016 G.C…………18

Figure: - 2 Illustrate distribution of intraoperative and postoperative body temperature for

pediatric patients who underwent surgery in Black lion specialized hospital from January-March
2016 G.C………………………………………………………………………………………...19
Figure: - 3 Illustrate the trend of intraoperative and postoperative body temperature for pediatric
patients who underwent surgery in Black lion specialized hospital from January-March 2016
G.C………………………………………………………………………………….……………20

V
ACRONYMS:

AAU: Addis Ababa University

ASA: American society of Anesthesiology

BMI: body mass index

BSA: Body Surface Area

BSc: Bachelor of science

C.I: confidence interval

EAA: Ethiopian Anesthetist Association

ENT: Ear Nose Throat

ETB: Ethiopian birr

GIT: Gastrointestinal trucks

GUH: Gondar University Hospital

IV: Intervenes

MOH: Ministry of Health

MSc: Master of science

OR: operation room

PACU: post anesthesia care unite

TASH: Tikur Anbessa Specialized Hospital

UK: United Kingdom

USA: United State of America

VAS: Visual Analogue Scale

VI
 CHAPTER ONE: INTRODUCTION
1.1.BACKGROUND:
Hypothermia is the most common intraoperative and postoperative disturbance in pediatric patients.
Pediatric patients are highly vulnerable to hypothermia and its associated complications, Pediatric patients
have a larger surface area per kilogram than adults. Metabolism and its associated parameters (oxygen
consumption, CO2 production, cardiac output, and alveolar ventilation) correlate better with surface area
than with weight [1].
Thin skin, low fat content, and a greater surface area relative to weight promote greater heat loss to the
environment in neonates. This problem is compounded by inadequately warmed operating rooms,
prolonged wound exposure, administration of room temperature intravenous or irrigation fluid, and dry
anesthetic gases [2]. Of course, there are also effects of anesthetic agents on temperature regulation. The
more important mechanisms for heat production in neonates are non-shivering thermogenesis by
metabolism of brown fat and shifting of hepatic oxidative phosphorylation to a more thermogenic pathway.
Metabolism of brown fat is severely limited in premature infants and in sick neonates who are deficient in
fat stores. Furthermore, volatile anesthetics inhibit thermogenesis in brown adipocytes [3].

Humans maintain constant body temperature despite of changes in external environment. Core body
temperature is maintained within narrow range; because enzyme systems in the body have narrow
temperature ranges in which they function optimally for caring out different activities in the body as
metabolism, conduction of nervous function and skeletal muscle contraction [4,5].

Hypothermia is defined as core body temperature of <36oC. It could be classified in to three as mild (35-
35.9oC), moderate (34-34.9oC) and severe when core body temperature is ≤33oC [6].

Pediatric Patients under Anesthesia and surgery can have altered thermoregulation due to different reasons.
These mechanisms include loss of normal response to heat loss (lack of shivering), increased heat loss to
environment when body cavity is opened to cold operation room environment, cooling effect of cold
anesthetic gases and reduced body heat production due to reduced metabolic rate [7].

Heat can be lost during surgery by different mechanisms. There are four means of heat loss. The dominant
one is heat loss by radiation which accounts for 60% of heat loss. Any objects with temperature above

1
absolute zero degree can loss heat to objects surrounding it. The second means of heat loss is heat loss by
conduction which is facilitated by temperature difference between the patient and objects. This type of heat
loss constitutes for 20% of heat loss during surgery [8, 9].

Heat loss by convection is another means of heat loss which occurs due to direct contact of the patient with
objects. Cold operation room table and cold OR attires facilitate this type of heat loss [10].

Evaporative and respiratory tract heat losses are other means of heat loss which are heat loss that occur via
skin and respiratory tract. Evaporative heat loss mainly occurs by use of cold skin preparation solutions,
while heat loss via respiratory system is facilitated by use of cold and dry anesthetic gases [11,12].

Mild intentional Hypothermia is sometimes induced in an attempt to reduce cerebral and myocardial
ischemia, but there are ample evidences that showed that hypothermia will have many adverse
consequences on surgical patients [13-17].

Hypothermia is one of common events during perioperative time and can have different consequences that
increase perioperative morbidity and mortality. A core temperature of less than 34°C is highly associated
with mortality due to coagulopathy, metabolic acidosis, multiple organ failure, hemodynamic instability
and infections [18].

Hypothermia depresses myocardial contractility; particularly depression of left ventricular contractility

occurs with mild hypothermia. It also results in both atrial and ventricular rhythm disturbances. The initial
response to hypothermia is sinus tachycardia which will progress to bradycardia if not corrected soon.
Hypothermia also blunts response of myocardium to catecholamine [16,19].

Hypothermia increases cardiac events such as myocardial ischemia and angina. The increased risk of
cardiac problems during perioperative time in the presence of hypothermia could be due to increased
vasoconstriction, increased level of nor adrenaline and altered alpha adrenoceptortone. Hypothermia also
interferes with anesthetic drugs’ metabolism that will lead to poor recovery [20] The prevalence of
perioperative hypothermia for pediatrics is not studied in country; hence the findings of this study is
expected to use as pillar for improve pediatrics management and further study to related issue.

2
1.2.STATEMENT OF THE PROBLEM:
Intraoperative and postoperative hypothermia is one of major problems during surgery that can affect 50-
90% of operated patients [7]. It has been shown by different researchers that hypothermia will result in to
various adverse events such as myocardial ischemia, coagulopathy, delayed awakening and wound
infections [21-23].
Various attempts had been tried by different investigators to reduce occurrence of perioperative
hypothermia. These attempts include warming of intra venous fluids using hot water bath of up to 54 oC
without adverse effects such as hemolysis. Another active warming technique is warming the patient
during operation using forced-air warming device [24-27]. None of these modern technique is present in
our set up, except for some efforts by anesthetists such as warming blood by using boiled water. This
method can have danger of lysis because there is no means to know the temperature. Since the Hospital is
the largest Referral Hospital in the country, the number of patients that visit the hospital increases from
time to time, sometimes beyond the capacity of the Hospital to handle [28].
Patients scheduled for operation have to wait outside the operation room (open field) which makes them to
be exposed to cold air; hence patients are already at risk of Hypothermia before they are operated; besides
there is no facility to warm patients actively. The administration of cold IV fluids, administration of
anesthetics and exposure of body cavity to cold operation room environment will further make them to loss
heat [29-31].
Though there was two studies conducted in Gondar university Hospital(GUH) which revealed that
incidence of postoperative hypothermia for all patients who underwent surgery in 2014 and perioperative
hypothermia and associated factors for all patients who underwent surgery in 2015, there is no study
conducted to determine incidence of intraoperative and postoperative hypothermia and associated factors
for pediatric patients who underwent surgery in TASH, hence this study is aimed to determine incidences
of intraoperative and postoperative hypothermia and local factors associated with it.

3
1.3.JUSTIFICATION OF THE STUDY:
TASH has been performing range of surgical procedures for the last fifty years. There is marked increase
in patient flow from time to time, while the operation room facility upgrade remained difficult compare to
patient flow increment. Even, health professionals not attention about their patient body temperature. The
same way, health managerial not seen to dispense any resources related body temperature measuring
materials where in governmental hospitals. So, all these poor facilities challenge to maintain normothermia
during perioperative.

Hypothermia affects pharmacokinetics of anesthetic agents and adjuvant drugs including sedatives, muscle
relaxants and volatile agents, coagulation system, postoperative wound infection system and causes both
hepatic and renal blood flow decrease that will in turn decrease drug metabolism and excretion. These
conditions in turn incur additional cost to patients and to the health facility. All these and other effects lead
temporary or permanent squall for children while their developing stages. One of Ethiopian millennium
development goal is reduction morbidity and mortality of children. Therefore, it is very important to
conduct research on intraoperative and postoperative hypothermia and associated risk factors which in turn
help the Hospital to decrease the incidence of hypothermia in pediatric patients.

The study will also helpful for program planners and policy makers so as to devise different strategies to
prevent or at least reduce risk factors of pediatric hypothermia.

Till date, there is no such study conducted in the study area so that it can be used as a base line data for
further researchers.

4
 CHAPTER TWO

2. LITERATURE REVIEW:

2.1 MONITORING OF TEMPERATURE:

Though distribution and heat content of the body not uniform, Core temperature, is the single best indicator
of thermal status in humans [7]

2.2. MONITORING SITES:

Pulmonary artery catheter is the gold standard measure of core temperature that is used as a reference for
other sites. But its use is limited by its being expensive and invasive and also risky. Esophageal
temperature monitor is another method of measuring core temperature that gives accurate measure if used
properly, but can be affected by the use of humidified gases during general anesthesia and during neuraxial
blocks and postoperative period its use can be inconvenient. Nasopharyngeal temperature can be recorded
with esophageal probe place above the palate. Tympanic membrane temperature monitoring is often the
preferred method in the preoperative and perioperative areas. The tympanic membrane is close to the
carotid artery and hypothalamus and is a noninvasive and accurate measure of core temperature [32-34].

Axillary temperature remains the most widely used and most convenient site for monitoring temperature in
children. However, the axillary site is a notoriously unreliable site to measure the core temperature because
the probes are often misplaced within the axilla leading to erroneous temperature measurements. The
axillary temperature may underestimate the core temperature if the room temperature is low or if room
temperature intravenous fluids are infused at high flow rates, particularly in small children when the
intravenous is infusing in the same extremity as the axillary temperature is monitored. In contrast, we have
documented unusually high axillary temperatures when the tip of the probe senses the hot air from a forced
warm air device. One study demonstrated that the axillary site may be as accurate for core temperature
estimation as the tympanic membrane, esophageal, and rectal temperature sites. The accuracy of the
axillary probe depends on carefully positioning the tip of the probe close to the axillary artery while
maintaining the arm tightly adducted [35].

5
The rectal site, which is easy to access and associated with minimal morbidity, can also provide accurate
core temperature measurements. However, these measurements may be inaccurate if the probe becomes
embedded in feces or is exposed to cool venous blood return from the legs or if readings become
influenced by the proximity of the probe to an open abdominal cavity during laparotomy or the bladder
while it is irrigated with either cold or warm fluids. Contraindications to the use of a rectal probe includes
imperforate anus, and relative contraindications include inflammatory bowel disease, rectal tumors,
neutropenia or thrombocytopenia, coagulopathy, and circumstances in which the bowel or bladder is being
irrigated [36].

Bladder temperature is equal to pulmonary artery (core) temperature, provided that there is high urine flow,
when urine flow is low it approximates rectal temperature [37,38]

2.3.INCIDENCE OF HYPOTERMIA

According to the study conducted in USA in 2010 on perioperative hypothermia, 52% of children
experienced intraoperative hypothermia. The result of the study also revealed that duration of hypothermia
ranged from 5-142 minutes (25 ± 22.8) and children who had invasive procedures (i.e., procedures
involving an incision) and those who had skin probe monitoring were more likely to have documented
hypothermia [39].

The study that done at yamanashi in Japan in 2002 and others studies, thin patients become more
hypothermic with more profound redistribution hypothermia than obese patients. Although intraoperative
factors affect thermoregulation during longer operations, preoperative patient characteristics are cardinal
factors for intraoperative hypothermia, which may cause serious complications postoperatively. Positive
thermal care, including pre-warming, can be administered to patients with a high probability of
hypothermia and this should reduce the occurrence of severe hypothermia and minimize the occurrence of
adverse effects [14,25,40,41,42].

In Ethiopia, Research conducted in University of Gondar Hospital in 2014 on postoperative hypothermia

for all age level showed that patient with high ASA physical status, operated under general anesthesia and
elective surgical patients were strongly associated with the development of postoperative hypothermia [44].

In other study conducted in the same Hospital in 2015 on Perioperative Hypothermia and Predictors of
Intra-Operative Hypothermia, the mean temperature on arrival was 36.3 with standard deviation of 0.7.
6
Incidence of hypothermia before and after induction was 23.4%,30.5% respectively. Most procedures were
completed within 1-2 hours. There were 90 patients whose procedure time was between 2-3 hours and the
incidence of hypothermia during this time was 72%. The overall incidence of intra operative hypothermia
was 49.7%. Of which mild hypothermia was seen among 37.5%, moderate and severe hypothermia were
seen among 10.3 and 1.9% respectively and the overall incidence of post-operative hypothermia was
50.6%. Moderate and severe hypothermia were seen among 36.9 and 5.4% of patients respectively. [5]

2.4.RISK FACTORS FOR INTRAOPERATIVE AND POSTOPERATIVE HYPOTHERMIA:

In a prospective observational study conducted in 2012, age, duration of anesthesia and pain in post
anesthesia care unit were found to be independent predictors of perioperative hypothermia. According to
this study, the incidence of Hypothermia was 42% among patients whose age was > or =65 years of age as
compared to 30% among those whose age was < 65 years of age. Median Anesthesia time of 110 minutes
was found to increase perioperative hypothermia as compared to median anesthesia time of 70 minutes.
Increased VAS score was also found to be independent predictor of perioperative Hypothermia [45]

In a randomized study conducted in 1997 on the role of irrigation in the development of hypothermiaduring
laparoscopic surgery, among patients who underwent laparoscopic surgery, amount of irrigating fluid
(ambient fluid) and duration of anesthesia were predictors of drop in core body temperature [47]

Another co relational study conducted by Vanessa de BritoPoveda and colleagues in 2009, among patients
operated on elective basis described that patient’s body temperature was positively correlated with mean
room temperature in theatre [48]

In the study conducted by Noriyoshi Tanaka in 2012, patients with perioperative high anxiety level were
found to be hypothermic as compared to those patients with low perioperative anxiety level. In this
particular study, out of 120 patients who were scheduled for major open abdominal surgery 51% developed
hypothermia [49].

7
 CONCEPTUAL FRAMEWOR

Pre-operative patient

Condition

 Coexisting
illness
 ASA status
 Medication

Socio-demographic
Intra operative medication
characteristics
and events
 Age
 Temperature
 Sex
 drugs
 Residence Hypothermia  type of anesthesia
 Weight
 IV fluids
 Height
 Duration of
Surgery
 Duration of
Anesthesia
Post-operative conditions  blood loss
 Transfusion
 pain
 Temperature
 IV fluids

8
 CHAPTER THREE

3. OBJECTIVE:

3.1.GENERAL OBJECTIVE:
To determine magnitude of intraoperative and postoperative hypothermia and associated factors among
pediatric patients operated in Tikor Anbessa Specialized hospital from January to March, 2016.

3.2.SPECIFIC OBJECTIVES:
1. To determine magnitude of intraoperative hypothermia among pediatric patients operated at Tikur
Anbessa Specialized Hospital;

1. To determine magnitude of postoperative hypothermia among pediatric patients operated at Tikur

Anbessa Specialized Hospital;

2. To identify factors associated with hypothermia among pediatric patients operated in Tikur Anbessa
Specialized Hospital

9
 CHAPTER FOUR
4. METHODOLOGY
4.1.STUDY AREA AND PERIOD:

This study was conducted in TikurAnbessa specialized Hospital (TASH) from January to March, 2016.
TASH is one of largest referral hospital in the country since 1998 and serves for all referred patients from
different part of the country. Annually more than 6,000 people operated for different surgical conditions in
the Hospital. The hospital has 8 operation beds which are located 3 in the main operation room, 1 in
obstetric unit,4 in Orthopedic and pediatric department. Majority of pediatric patients were operated in the
Orthopedic and pediatric theatre which was built unplanned for operation room.

4.2.STUDY DESIGN:
Cross sectional study designwas conducted

4.3.SOURCE POPULATION:

All Pediatric patients that undergone elective surgical procedure atTikur Anbessa specialized Hospital

4.4.STUDY POPULATION:Selectedelectivepediatricpatients that undergo surgeries at TASHwithin

specified time period.
4.5.EXCLUSION CRITERIA: Patients with fever, preoperative hypothermic, anesthesia time less
than 30 minutes and those patients that bypass recovery and pediatric patients whose parents are not
available to sign the consent at the time of data collection were excluded from this study.

10
 4.6.SAMPLING AND SAMPLE SIZE DETERMINATION:

All consecutive elective pediatric patients who were scheduled for surgery at TASH within specified time
period were included so that there was no any sampling technique used.

4.7.VARIABLES OF THE STUDY:

4.7.1. Dependent variable. Intraoperative and postoperative hypothermia.
4.7.2. Independent variables

Socio-demographic variables: age, sex, weight, Residence, Educational status, Occupation, Height

Preoperative clinical condition of the respondents: ASA status, coexisting diseases, body surface area
Intraoperative related factors: like type of surgery, type of anesthesia, duration of surgery, duration of
anesthesia, amount of blood loss, operation room temperature, amount of intravenous fluid administered,
blood transfusion and induction agents used.

4.8.DATA COLLECTION TOOLS:

The structured questioner was filled by trained data collectors (2 BSC anesthetists). The data collectors
were assign one for elective pediatric procedures and one for elective orthopedic procedures including
Urology, thoracic procedures. The questioner was prepared in English.

4.9.BODY TEMPRATURE MEASURMENT:

Body temperature was taken preoperatively, intra operatively and post operatively. The intra operative
temperature was taken before induction, immediately after induction and then every hour till the procedure
was finished. The post-operative temperature was taken every hour up to 2 hours considering that patients
stay in the post Anesthesia care unit 1-2-hour post operatively. This measurement was done using tympanic
thermometer.

Tympanic membrane temperature monitoring is often the preferred method in the preoperative and
perioperative areas. The tympanic membrane is close to the carotid artery and hypothalamus and is a
noninvasive and accurate measure of core temperature (50).

11
4.9.DATA ANALYSIS PROCEDURE:

Data was entered into Epi info version 7 and exported to SPSS version 20 for analysis. Tables and figures
were used to describe descriptive results. Binary Logistic regression was used to test each factor with the
dependent variable, and variables with P value of <0.2 were carried to multi variant analysis. 95% C.I. and
P value of <0.05 was used as a cutoff point to test for significance of associations.

4.10. DATA QUALITY CONTROL:

Data collectors were trained. Pre testing of questionnaires was done before the start of the actual data
collection to check for validity of the questionnaires’ and feasibility of the method. Close supervision was
done during data collection. Each Questionnaire was checked for errors before entry. Double entry was
done on epi info version 7 on 10% of sample size.

4.11. ETHICAL CONSIDERATION

After approval of proposal, ethical clearance was obtained from ethical review committee, Anesthesia
department, Addis Ababa University. Permission to conduct research was obtained from Tikur Anbessa
Specialized Hospital. Informed verbal consent was obtained from every study participant. Confidentiality
of information was ensured.

4.12. OPERATIONAL DEFINITIONS:

Minor surgery: is any invasive operative procedure in which only skin or mucus membranes and
connective tissue is resected e.g. vascular cut down for catheter placement, implanting pumps in
subcutaneous tissue, Breast biopsy…etc.

Moderate surgery: - Any invasive procedure which involves removal of skin and subcutaneous lesions.
The expected blood loss is <10% of total blood volume. Examples include, Cystoscopy, vasectomy, Fiber
optic bronchoscopy, Diagnostic laparoscopy, dilatation and curettage, arthroscopy, Inguinal hernia repair,
Laparoscopic lysis of adhesion…etc.

12
Major Surgery: - These are procedures with expected blood loss of 10%-30% of total blood volume,
includes invasive procedures such as, Open thoracic or intracranial procedure, thyroidectomy,
Hysterectomy, major vascular repair (e.g., aorta- femoral bypass) …etc.

Normothermia: A core temperature range of 36°C to 38°C (96.8°F to 100.4°F)

Hypothermia: A core temperature less than 36°C (96.8°F)

Hyperthermia: A core temperature greater than 38°C (100.4°F)

13
 CHAPTER FIVE
5. RESULT

Personal and socio-demographic characteristics

Data was collected from 92surgical pediatric patients. Two pediatrics patients were excluded because they
had elevated body temperature during procedure. The mean age of participants was 5.63 years with
standard deviation of 4.40, minimum age was 26 days and maximum age was 14 years old. The proportion
of male participants was 71.1 %( n=64). Majority of participants were American society of
Anesthesiologists’ class I (ASAI) (93.3%). Six (6.7%) of participants had co morbidity. The leading co
morbidity was malnutrition (66.7%). The mean operation room temperature was 21.42°C with standard
deviation of 1.87.

Of the total 90 cases, the highest number of cases 40%( n=36) were belonged to the age group of 6 –12
years old followed by age group between 2-5 year, (31%). And more than half of the respondents were
urban residence 63.3%(n=66). None of them preoperative hypothermia. Table 1 illustrate these and
additional information.

Variables Category Frequency Percentage

Frequency Percent
Neonate (0-30 days) 1 1.1
Infant(1-12 months) 16 17.8
Toddler(2-5 years) 31 34.4
Age distribution of respondent Children(6-12)years 36 40.0
Adolescent t(13-18
6 6.7
years)
Total 90 100.0
Male 64 71.1
sex distribution of respondent Female 26 28.9
Total 90 100.0
Orthodox 55 61.1
religion of respondent Protestant 12 13.3
Muslim 19 21.1
14
 Others 4 4.4
Total 90 100.0
Oromo 40 44.4
Amhara 31 34.4
ethnicity of respondent
Tiger 6 6.7
Others 13 14.4
Total 90 100.0
Urban 66 73.3
residence of respondent Rural 24 26.7
Total 90 100.0

Table: - 1 Personal and socio-demographic characteristics pediatric surgical patients at TikurAnbessa

Specialized Hospital January-March 2016 G.C

Preoperative clinical condition of the respondents

Majority of respondents were free of coexisting diseases 93.3%(n=84) while 6.7% of cases were associated
with other diseases. Most of the respondents were grouped asASA classIand the least of them were
grouped under ASA III. Of all the respondent 67.8%(n=61) operated at morning time.More than half
procedures were pediatric surgical cases follow by Orthopedic, Urologic, cardiothoracic procedures,as
table 2 shows below.

Variables Category Frequency Percent

Yes 6 6.7
any coexisting
No 84 93.3
illness
Total 90 100.0
ASA I 84 93.3
ASA II 5 5.6
ASA status
ASA III 1 1.1
Total 90 100.0
less than 0.5 m2 of BSA 22 24.4
between 0.5 m2 and 1.00 m2 of
Body surface 51 56.7
BSA
area
greater than 1 m2 of BSA 17 18.9
Total 90 100.0
Time of arrival Morning 61 67.8

15
 Afternoon 29 32.2
Total 90 100.0
orthopedic procedures 30 33.3
pediatrics procedures 48 53.3
Surgical cardiothoracic procedures 4 4.4
procedure
ENT procedures 1 1.1
Urology procedures 6 6.7
GIT procedures 1 1.1
Total 90 100.0

 BSA=body surface area, GIT=gastrointestinal truck, ENT=ear nose throat, ASA=American society
of anesthesiologist.

Table: - 2 Shows Preoperative clinical condition of the respondents or pediatric patients who underwent
surgery in Black lion specialized hospital from January-March 2016 G.C.

Intraoperative events for respondents and frequency

Almost half of the procedures operated in OR temperature between 20-23 degree Celsius, as described in
Table 3, major induction agent was propofol 43.3%(n=39) followed by combination of propofol and
inhalational 35.6%(n=32) anesthetics. Thirty of all respondents had been given nerve block and most
block was a caudal block 80%(n=24). Most of respondents were given cold (room temperature) iv fluid
and a few of respondents were given warm fluid. More than half of the cases had been token 61-120
minutes.

Variables Category Frequency percent

less than 20 0C of room
23 25.6
temperature
OR temperature
between 20-23 0C of room
44 48.9
temperature
greater than 23 0C 23 25.6
Total 90 100.0
Inhalational 2 2.2
propofol ,inhalational 32 35.6
Ketamine 3 3.3
Induction agents propofop, ketamine 8 8.9
Thiopantane 1 1.1
thiopantone, ketamine 2 2.2
Propofol 39 43.3

16
 Total 90 100.0
Suxamitanium 53 82.8
Vecronium 9 14.1
Muscle relaxants Pacronium 1 1.6
cis atracurium 1 1.6
Total 64 100.0
Caudal 24 80.0
intercostal block 4 13.3
Name of block
axillary block 2 6.7
Total 30 100.0
Pethidine 41 83.7
Morphine 1 2.0
Tramadol 4 8.2
Analgesics used pethidine, tramadol 1 2.0
paracetamol, diclofenac 1 2.0
morphine, paracetamol 1 2.0
Total 49 100.0
less than or equal 9ml/kg 24 26.7
10-19 ml/kg 21 23.3
Total iv fluids used
20-29 ml/kg 25 27.8
intraoperatively
greater or equal 30 ml/kg 20 22.2
Total 90 100.0
Room temperature 81 90.0
Temperature of IV
warm fluid 9 10.0
fluids
Total 90 100.0
less than 60 minute duration 3 3.3
between 61-120 minutes duration 51 56.7
Duration of surgery between 121-180 minutes duration 33 36.7
between 181-240 minutes duration 3 3.3
Total 90 100.0
less than 60 minute duration 4 4.4
Duration of anesthesia
between 61-120 minutes duration 42 46.7
between 121-180 minutes duration 38 42.2
between 181-240 minutes duration 6 6.7
Total 90 100.0
IV=intervenes

Table: -3 Illustrate Intraoperative events for respondents or pediatric patients who underwent surgery in
Black lion specialized hospital from January-March 2016 G.C.

17
Figure-1 shows the average intraoperative body temperature distribution which implied 71% hypothermia
and 29% normothermia.

intraoperative body temperature

26, 29%

64, 71%

normothermia hypothermia

Figure: - 1 Distribution of averageintraoperative body temperature for pediatric patientswho underwent

surgery in Black lion specialized hospital from January-March 2016 G.C.

18
As below diagram below illustrate, the frequency of postoperative hypothermia greater than intraoperative
hypothermia in pediatric patients. Which implies 71% for average intraoperative and 79% for postoperative
hypothermia.

intraoperative postoperative

80
71
70 64
60

50

40

30 26
19
20

10

0
hyothermia normothermia

Figure: - 2 Illustrate distribution of intraoperative and postoperative body temperature for pediatric
patients who underwent surgery in Black lion specialized hospital from January-March 2016 G.C.

19
Figure: - 3 Illustrate patients’ body temperature from induction, hourly interval and postoperative. The
diagram implied that just after induction incidence of hypothermia 72.2%, after an hour of induction
64.4%, after couple of hours again raised to 83.8% and after third hours there were three cases but all had
been hypothermic. Addition to that the figure replied postoperative incidence of hypothermia 78.9% of all
pediatric patients.

The trend of body temprature

100

90

80

70

60 58
65
71
50
90
40

30

20 31
32
25
10 19
6 3
0
Body temprature Body temprature Body temprature Body temprature Body temprature Body temprature
during arrival just after after 1st hr after 2nd hrs after 3rd hrs postoperatively
induction induction induction induction

Normothermia hypothermia

Figure: - 3 Illustrate the trend of intraoperative and postoperative body temperature for pediatric patients
who underwent surgery in Black lion specialized hospital from January-March 2016 G.C

20
As multivariate association implied body surface area, total Iv fluid and OR temperature was strongly
associated with intraoperatively hypothermia at p value less than 0.05. The odd of developing
intraoperative hypothermia for urban resident was seven times as high as the odd of developing
intraoperative hypothermia for rural resident (AOR; 7.168; C.I, 1.509-34.050).

Variables Category p-value AOR 95% C. I .for

EXP(B)

Lower Upper
2
Body surface area <0.5m .693
0.5-1 m2 .398 2.298 .334 15.816
>1 m2 .669 1.411 .291 6.842
Sex Male * * * *
Female .607 1.448 .353 5.934
Residence Urban * * * *
Rural .013 7.168 1.509 34.050
OR temperature <20 .001 * * *
21-23 .001 .011 .001 .145
>23 .002 .095 .021 .431
Total iv fluids used intraoperatively <9ml/kg .133 * * *
10-19ml/kg .023 13.031 1.422 119.370
20-29ml/kg .034 11.631 1.200 112.784
30-39ml/kg .104 6.341 .682 58.963
Table: - 4 The association of variables to intraoperative hypothermia for pediatric patients who underwent
surgery in Black lion specialized hospital from January-March 2016 G.C.

A data from multivariate analysis implied OR temperature was strongly associated with postoperatively
hypothermia at p value less than 0.05. The odd of developing postoperative hypothermia for body surface
area0.5-1 m2was twice as high as the odd of developing postoperative hypothermia for body surface area
<0.5m2 (AOR; 1.915; C.I, .296-12.387). The odd of developing postoperative hypothermia for average
intraoperative hypothermia five times as high as the odd of developing postoperative hypothermia for
intraoperative normothermia (AOR; 4.687; C. I, .824-26.670).As (table-5) Females were three times more
vulnerable for postoperative hypothermia than male pediatric patients (AOR;3.001; C.I,.650-13.860).

21
Variables Category p-value AOR 95% C. I. for
EXP(B)
Lower Upper
Body surface area <0.5m2 .603
0.5-1 m2 .495 1.915 .296 12.387
>1 m2 .916 .920 .197 4.298
Sex Male * * * *
Female .159 3.001 .650 13.860
Residence Urban * * * *
.626 .671 .135 3.341
Rural
ORtemperature <200C .028 * * *
21-230C .033 .096 .011 .831
>230C .535 .556 .087 3.555
Totalivfluids <9ml/kg * * * *
10-19ml/kg .142 4.226 .616 29.000
20-29ml/kg .269 2.703 .464 15.749
30-39ml/kg .214 2.864 .545 15.057
Average intraoperative body * * * *
Normothermia
temperature
Hypothermia .082 4.687 .824 26.670
Table: - 5 Illustrate the association of variables topostoperative hypothermia for pediatric patients who
underwent surgery in Black lion specialized hospital from January-March 2016 G.C

22
 CHAPTER SIX: DISCUSSION

In this review, intraoperative hypothermia was assessed on pediatric surgical patients. The mean age of
participants was 5.63 years with standard deviation of 4.40. It wasalso found that the incidence of intra and
post-operative hypothermia was 71.1% and 78.9% respectively. Intra-operative hypothermia was observed
in 64 (71.1%) patients with body temperature ranging from 34.18 to 35.9°C. This incidence is higher when
compared with study conductedat Gondar University Hospital [5], where incidence of intra operative was
49.7%, but lower than in study conductedin Australia where the incidence was 74% [5, 41].

Similarly, another study showed that more than 50% of children experienced intraoperative hypothermia
[34]. Furthermore, this study found that children who were operated at low ambient temperature were
highly vulnerable to hypothermia than children who were operated in high ambient temperature which is
consistent to a study conducted on intraoperative hypothermia and showed as operation room temperature
was critical factor for intraoperative patient’s body temperature [51].

Another study done in India in 2014 implied that, during pediatric anesthesia infants and small children are
prone to perioperative hypothermia due to many inherent factors. This makes it mandatory to monitor their
core temperature. Management should involve prevention and/or decreasing the risk by use of a
multimodal approach. This includes preoperatively keeping the child warm, increasing ambient OR
temperature to 23 0C-25 0C, use of warm intravenous fluids, passive insulation and use of forced air
[warming devices [43].

According to the result of this study, total IV fluid used intraoperative was associated with intraoperative
and postoperative hypothermia which is consistent other study [52]. A review of this study was also
demonstrated that low operative room temperature was strongly associated with intraoperative
hypothermia. Similarly, Intravenous fluid temperature was found to be associated with incidence of
hypothermia in a prospective observational study conducted in 2012 by FrédéricLapostolle and colleagues
among trauma victim patients. In this particular study, severity of injury and mobile unit temperature were
also highly associated with perioperative hypothermia among trauma victims [46]

23
Perioperative core temperatures are modulated by changes in the internal distribution of body heat and by
systemic heat balance. Heat balance is, in turn, largely determined by ambient exposure, which includes the
effect of passive insulation [53] and active heating [54]. Core temperature in our hypovolemic patients
increased, whereas temperature decreased in those who were given larger amounts of fluid. The magnitude
or even direction of the changes would presumably vary in other environments. However, the relative
effect of mild fluid deprivation is likely to be similar under other conditions.

In contrast to this study, intraoperative a study conducted on factors affecting perioperative hypothermia
revealed that operative room temperature has no impact on intraoperative and postoperative [ 46] In other
similar study conducted on Perioperative Hypothermia and Predictors of Intra-Operative Hypothermia
showed that the mean temperature on arrival was 36.3 with standard deviation of 0.7. Incidence of
hypothermia after induction was 23.4%. [5] In the present study, Incidence of hypothermia after induction
was 72.2%. The likely cause of the difference may be due to temperature variation in different
geographical area and intraoperative clothing style of the patient was different.

24
 CHAPTER SEVEN: Conclusion and RECCOMENDATION

7.1 Conclusion

This study revealed a high incidence of inadvertent intraoperative and postoperative hypothermia in
electivepediatric operated cases. A relatively high incidence of hypothermia was found in patients who
operated in low ambient temperature.
Residence, OR temperature, total iv fluids used intraoperatively were strongly associated with
intraoperative hypothermia.
Body surface area, sex, totalivfluids and average intraoperative body temperature were positive predictor of
postoperative hypothermia.

7.2 RECCOMENDATION

Based on the finding of the study the following recommendations are drawn
 Anesthetist should warm Iv fluid before they infusion
 PACU team should monitor their patients body temperature as route standard when monitor the
patients in recovery.
 Hospital administrative should adjust Operative room temperature between 23-250C
 Researcher were recommended to conduct further researchers using cohort study design.

25
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13. Tsuei BJ KP. Hypothermia in the trauma patient. Injury. 2004;(35):7-15.
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29. Fritz HG BR, Walter B, Moertiz KU, Reinhart K. ffects of hypothermia (32uC) on plasma
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30. Heier T CJ, Sessler DI, Miller RD. Mild intraoperative hypothermia increases duration of action and
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1991;74(5):815-9.
31. Heier T CJ, Sharma ML, et al. Mild intraoperative hypothermia does not change the
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analgesia. 1994;78:973–7
32. Caldwell J E, Heier T, Wright P M, Lin S, McCarthy G, Szenohradszky J, Sharma M L, Hing J P,
Schroeder M and Sessler D I: Temperature-dependent Pharmacokinetics andpharmacodynamics of
Vecuronium. Anesthesiology 2000, 92:84-93
33. Anthony G. Doufas. Consequences of inadvertent perioperative hypothermia.Best Practice & Research
Clinical Anaesthesiology 2003; 17 (4) : 535–549,
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Prevalence, Risk Factors and Outcomes. J Anesthe Clinic Res.2010;1(1):1-4.
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37. T. Kasai, M. Hirose, K. Yaegashi, et al.Preoperative Risk Factors of Intraoperative Hypothermia in
Major Surgery Under General Anesthesia. AnesthAnalg. 2002;95:1381–3.
38. Kiekkas P KM. Prewarming: preventing intraoperative hypothermia. Br J Perioperative Nursing.
2005:444-51.
39. Siegel M N, Gravenstein N. Passive warming of airway gases (artificial nose) improves accuracy of
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40. Lenhardt R. Monitoring and thermal management: Best Pract Res ClinAnaesthesiol2003
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42. Salzberg Moore et al. ][Susan Salzberg Moore, MD, a Carmen R. Green, MD, b Feng Lei Wang, MD,"
Sujit K. Pandit, MD, b and William W. Hurd, M])":The role of irrigation in the development of
hypothermiaduring laparoscopic surgery.AmJObstet Gynecol. March 1997.
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Developing Intraoperative Hypothermia? AnesthAnalg2002;94:215–20.
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Patients at University of Gondar Hospital.Anesthesia&ClinicalJAnesthClin Res.2014; 5:11
45. Clara Luís1, Carlos Moreno1, Acácio Silva1, Rosália Páscoa1, Fernando Abelha, Inadvertent Postoperative
Hypothermia at Post-Anesthesia Care Unit: Incidence, Predictors and Outcome. Open Journal of
Anesthesiology, 2012, 2, 205-213.
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Savary6,Karim Tazarourte7, Gerald Egman8, Lynda Mzabi1,2, Michel Galinski1,2 and Frédéric
Adnet1,2: Risk factors for onset of hypothermia in trauma victims. Biomed central. Critical Care 2012,
16:R142
47. Salzberg Moore et al. ][Susan Salzberg Moore, MD, a Carmen R. Green, MD, b Feng Lei Wang, MD,"
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hypothermiaduring laparoscopic surgery.AmJObstet Gynecol. March 1997.
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Preoperative Anxiety Level and the Risk of Intraoperative Hypothermia: International Journal of
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53. Sessler DI, Schroeder M: Heat loss in humans covered with cotton hospital blankets. AnesthAnalg993;
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30
ASSURANCE OF PRINCIPAL INVESTIGATOR

The undersigned agrees to accept responsibility for the scientific ethical conduct of the research project and
for provision of required progress reports as:

Per terms and conditions of the research publications office in effect at the time of Grant is forwarded as
the result of this application.

Name of the student: MulatMossie (BSc, MSc student in Anesthesia)

Date: 03/6/2016 G.C

Signature: ___________________________________

Approval of the primary advisor:

Name of the primary advisor: Mr.WesenyelehAdmasu (BSc, MSc)

Date: _______________________________

Signature:___________________________________

31
ANNEXES:
Questionnaire
Instruction: For each of the questions, please circle the number of alternative(s) that fit the response or fill
the blank space provided.

Questionnaire code ________ Date___________ Starting time ________

Section I: Questions about the Sociodemographic and clinical background of the respondents:

S. No Questions Answer If No, Skip to

101 Age _____yrs

102 Sex 1. Male

2. Female
103 Religion 1. Orthodox
2. Protestant
3. Muslim
4. Others
104 Ethnicity 1. Oromo
2. Amhara
3. Tigre
4. Others,specify………………….
105 Residence 1. Urban
2. Rural
106 Educational status 1. Unable to read & write
2. Read and write only
3. Primary school
4. Secondary school
5. Not applicable
107 Occupation 1. Farmer
2. Governmental employee
3. Merchant
4. Student
5. Others

32
Section II: Questions about Pre-Operative Anesthetic Evaluation:

S. No Questions Answer If No, Skip to

201 Type of surgery 1. Elective

2. Emergency
202 Surgical procedure 1.----------

203 Any co existing illness 1. Yes

2. No
204 If yes; name of the disease ------------

205 1. ASA I
ASA status 2. ASA II
3. ASA III
4. ASA IV

206
Weight -----------Kg

207 Height -----------M

208 On any medication 1. Yes

2. No

Base line BP _________ mmHG

HR -------------beat/m

Temperature ------------0C

RR --------breath/m

33
Section III: Questions about intra operative medication and events:

S. No Questions Answer If No, Skip to

301 Body temperature on arrival to ---------0C
OR
Time of arrival--------------
After induction --------------
After 1 hour of procedure --
After 2 hours of surgery ----
After 3 hours of surgery-----
After 4 hours of surgery----------
-----
302 OR temperature -------------- ---------0C
303 Induction Agent 1. Ketamine
2. Thiopental
3. Propofol
4. Inhalational(hal,Isofl,sevo)underline
one
5. Fentanyl
304 Muscle relaxant 1. Suxamethonium
2. Vecuronium
3. Pancuronium
4. Atracurarium
305 Analgesics ---------------------
306 Type of Local Ans.if spinal 1. Bupivacaine
2. Lidocaine
307 Name of block if any --------------------
308 Volume of LA for block -------------------ml
309 Temperature of IV fluids ----------------OC
310 Total IV fluids used intra ---------ml
operatively
311 Duration of Surgery ---------minutes
312 Duration of Anesthesia ---------minutes

34
313 Intra operative blood loss ---------------ml
314 Transfusion 1. Yes
2. No
315 If yes, how many units? --------------------
316 Urine out put --------ml
317 Monitors used 1. Pulse oxymetry
2. Capnography
3. NIBP
4. ECG
5. Thermometer
318 Intraoperative complication if ----------------
any
Section IV: Questions on post-operative conditions:
S. No Questions Answer If No, Skip to
401 Body temperature 1st. Record ……….0C
2nd.Record ……… ″ ″
3rd. Record ……… .″ ″
402 Shivering 1. Yes
2. No
BP _________ mmHG
HR --------------/m
Temperature ------------0C
RR --------/m

35
INFORMATION SHEET AND CONSENT FORM:
Title of the Research Project:

Intraoperative and postoperative hypothermia and associated factors, in elective surgical pediatric
patientsfrom January to March, 2016 in TikurAnbessaSpecialized hospital, Ethiopia.

Name of the principal investigator: MulatMossie

Name of the organization: AddisAbaba University, school of medicine, department of anesthesia.

Name of the sponsor: AddisAbaba University.

Introduction

This information was prepared with the aim of assessing the magnitude and associated risk factors of
Intraoperative and postoperative hypothermia in TASH. The research group includes the principal
investigator, two data collectors, and one advisor from AAU.

Purpose of the Research project

The aim/goal of this study was to determine the magnitude and the risk factors for intraoperative and
postoperative hypothermia during pediatric surgery at TASH. The finding of this study is expected to be
used by decision makers, MOH, EAA, Pediatric surgery department, department of anesthesia and health
practitioners of the University to change modifiable factors.

Procedure

This study wasincluding all elective pediatric patients coming for operation cases during the study period.
They were selected as part of the study participants whowere willing to participate in this study and willing
to have consent. No one was refused to participate during study pried.

Benefits, Risk or Discomfort

There was no direct benefit to study participants, but there was close monitoring and follow up. And the
result of this study used for further improvement of the service.There was no risk of participating in this
study.

36
Confidentiality: The information collected from the study subjects was kept confidential and stored in the
file, without their name by assigning a code number to each.

Right to refusal or withdraw

Study subjects washave full right to refuse from participating in this research.

Person to contact

For any questions or concerns you can contact the principal investigator using the following addresses:

Name: MulatMossie

Phone: +251910469914

E-mail: [email protected]

37
STUDY SUBJECTS CONSENT FORM

Consent form
Hello! My name is ___________ I am of the members of the research team and I am here to ask you some
questions and to collect some important information from your chart. Your name will not be listed out, that
means your confidentiality will be kept. If you are willing to participate in this research on the assessment
of magnitude and risk factors for perioperative hypothermia, which I will appreciate the contribution you
will made to this research. So I would like to ask you, if you are willing to participate in this research.
I understood about the objectives of the research and the roles I will have in the research. I have agreed to
participate in the research.

B. Agree B. Disagree
 If Respondent agrees to be interviewed, the interview will be started.

38