0
April 9, 1997, Vol 277, No. 14 >
ARTICLE | April 9, 1997

Perioperative Maintenance of Normothermia Reduces the Incidence of Morbid Cardiac Events: Title and subTitle BreakA Randomized Clinical Trial FREE

Steven M. Frank, MD; Lee A. Fleisher, MD; Michael J. Breslow, MD; Michael S. Higgins, MD; Krista F. Olson; Susan Kelly, BSN; Charles Beattie, MD
[+] Author Affiliations

Reprints: Steven M, Frank, MD, Carnegie 442, Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287 (e-mail: sfrank@welchlink.welch.jhu.edu).


JAMA. 1997;277(14):1127-1134. doi:10.1001/jama.1997.03540380041029
Text Size: A A A
Published online
Article
References

Objective.  —To assess the relationship between body temperature and cardiac morbidity during the perioperative period.

Design.  —Randomized controlled trial comparing routine thermal care (hypothermic group) to additional supplemental warming care (normothermic group).

Setting.  —Operating rooms and surgical intensive care unit at an academic medical center.

Subjects.  —Three hundred patients undergoing abdominal, thoracic, or vascular surgical procedures who either had documented coronary artery disease or were at high risk for coronary disease.

Outcome Measure.  —The relative risk of a morbid cardiac event (unstable angina/ischemia, cardiac arrest, or myocardial infarction) according to thermal treatment. Cardiac outcomes were assessed in a double-blind fashion.

Results.  —Mean core temperature after surgery was lower in the hypothermic group (35.4±0.1°C) than in the normothermic group (36.7±0.1°C) (P<.001) and remained lower during the early postoperative period. Perioperative morbid cardiac events occurred less frequently in the normothermic group than in the hypothermic group (1.4% vs 6.3%; P=.02). Hypothermia was an independent predictor of morbid cardiac events by multivariate analysis (relative risk, 2.2; 95% confidence interval, 1.1-4.7; P=.04), indicating a 55% reduction in risk when normothermia was maintained. Postoperative ventricular tachycardia also occurred less frequently in the normothermic group than in the hypothermic group (2.4% vs 7.9%; P=.04).

Conclusion.  —In patients with cardiac risk factors who are undergoing noncardiac surgery, the perioperative maintenance of normothermia is associated with a reduced incidence of morbid cardiac events and ventricular tachycardia.

REFERENCES

1 +
Ozaki M, Kurz A, Sessler DI, et al.  Thermoregulatory thresholds during epidural and spinal anesthesia . Anesthesiology . 1994;;81:282-288.
2 +
Kurz A, Sessler DI, Schroeder M, Kurz M.  Thermoregulatory response thresholds during spinal anesthesia . Anesth Analg . 1993;;77:721-726.
3 +
Sessler DI, Olofsson CI, Rubinstein EH, Beebe JJ.  The thermoregulatory threshold in humans during halothane anesthesia . Anesthesiology . 1988;;68: 836-842.
4 +
Sessler DI, Rubinstein EH, Moayeri A.  Physiologic responses to mild perianesthetic hypothermia in humans . Anesthesiology . 1991;;75:594-610.
5 +
Frank SM, Beattie C, Christopherson R, et al.  Epidural versus general anesthesia, ambient operating room temperature, and patient age as predictors of inadvertent hypothermia . Anesthesiology . 1992;;77:252-257.
6 +
Vaughan MS, Vaughan RW, Cork RC.  Postoperative hypothermia in adults: relationship of age, anesthesia, and shivering in rewarming . Anesth Analg . 1981;;60:746-751.
7 +
Morris RH.  Operating room temperature and the anesthetized, paralyzed patient . Arch Surg . 1971;; 102:95-97.
8 +
Krenzischeck DA, Frank SM, Kelly S.  Forcedair skin-surface warming vs. routine thermal care and core temperature monitoring sites . J Postanesth Nurs . 1995;;10:69-78.
9 +
Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A.  Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty . Lancet . 1996;;347:289-292.
10 +
Kurz A, Sessler DI, Lenhardt R, and the Study of Wound Infection and Temperature Group.  Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization . N Engl J Med . 1996;;334:1209-1215.
11 +
Frank SM, Higgins MS, Breslow MJ, et al.  The catecholamine, cortisol, and hemodynamic responses to mild perioperative hypothermia: a randomized clinical trial . Anesthesiology . 1995;;82:83-93.
12 +
Frank SM, Raja SN, Fleisher LA, Beattie C, Higgins MS, Breslow MJ.  Cardiovascular and adrenergic manifestations of cold stress . In: Zeisberger E, Schonbaum E, Lomax P, eds. Thermal Balance in Health and Disease: Recent Basic Research and Clinical Progress . Basel, Switzerland: Birkhäuser Verlag; 1994;:325-331.
13 +
Frank SM, Higgins MS, Fleisher LA, Sitzmann JV, Raff H, Breslow MJ.  The adrenergic, respiratory, and cardiovascular effects of core cooling in humans . Am J Physiol . 1997;;272:R557-R562.
14 +
Sessler DI.  Perianesthetic thermoregulation and heat balance in humans . FASEB J . 1993;;7:638-644.
15 +
Bay J, Nunn JF, Prys-Roberts C.  Factors influencing arterial P02 during recovery from anaesthesia . Br J Anaesth . 1968;;17:398-407.
16 +
Mangano DT.  Perioperative cardiac morbidity . Anesthesiology . 1990;;72:153-184.
17 +
Slogoff S, Keats AS.  Does chronic treatment with calcium entry blocking drugs reduce perioperative myocardial ischemia? Anesthesiology . 1988;; 68:676-680.
18 +
Lieberman RW, Orkin KF, Jobes DR, Schwartz AJ.  Hemodynamic predictors of myocardial ischemia during halothane anesthesia for coronary artery revascularization . Anesthesiology . 1983;;59:36-41.
19 +
Nelson AH, Fleisher LA, Rosenbaum SH.  The relationship between postoperative anemia and cardiac morbidity in high risk vascular patients in the ICU . Crit Care Med . 1993;;21:860-866.
20 +
Tofler GH, Brezinski DA, Shafer AI, et al.  Concurrent morning increase in platelet aggregability and the risk of myocardial infarction and sudden cardiac death . N Engl J Med . 1987;;316:1514-1518.
21 +
Frank SM, Beattie C, Christopherson R, et al.  Unintentional hypothermia is associated with postoperative myocardial ischemia . Anesthesiology . 1993;;78:468-476.
22 +
Bainton D, Moore F, Sweetnam P.  Temperature and deaths from ischemic heart disease . Br J Prev Soc Med . 1977;;31:49-53.
23 +
Rose G.  Cold weather and ischaemic heart disease . Br J Prev Soc Med . 1966;;20:97-100.
24 +
Lassvik CT, Areskog NH.  Angina in cold environment: reactions to exercise . Br Heart J . 1979;; 42:396-401.
25 +
Epstein SE, Stampfer M, Beiser GD, Goldstein RE, Braunwald E.  Effects of a reduction in environmental temperature on the circulatory response to exercise in man: implications concerning angina pectoris . N Engl J Med . 1969;;280:7-11.
26 +
Juneau M, Johnstone M, Dempsey E, Waters DD.  Exercise-induced myocardial ischemia in a cold environment . Circulation . 1989;;79:1015-1020.
27 +
Mudge GH Jr, Grossman W, Mills RM Jr, Lesch M, Braunwald E.  Reflex increase in coronary vascular resistance in patients with ischemic heart disease . N Engl J Med . 1976;;295:1333-1337.
28 +
Kurz A, Plattner O, Sessler DI, Huemer G, Redl G, Lackner F.  The threshold for thermoregulatory vasoconstriction during nitrous oxide/isoflurane anesthesia is lower in elderly than in young patients . Anesthesiology . 1993;;79:465-469.
29 +
Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau JF, Tateo IM, for the Study of Perioperative Ischemia Research Group.  Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery . N Engl J Med . 1990;;323:1781-1788.
30 +
Hollenberg M, Mangano DT, Browner WS, London MJ, Tubau JF, Tateo IM.  Predictors of postoperative myocardial ischemia in patients undergoing noncardiac surgery . JAMA . 1992;;268:205-209.
31 +
Rubinstein EH, Sessler DI.  Skin-surface temperature gradients correlate with fingertip blood flow in humans . Anesthesiology . 1990;;73:541-545.
32 +
Ramanathan NL.  A new weighting system for mean surface temperature of the human body . J Appl Physiol . 1964;;19:531-533.
33 +
Christopherson R, Beattie C, Frank SM, et al.  Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery . Anesthesiology . 1993;;79:422-434.
34 +
Fleisher LA, Rosenbaum SH, Nelson AH, Jain D, Wackers FJ, Zaret BL.  Preoperative dipyridamole thallium imaging and ambulatory electrocardiographic monitoring as a predictor of perioperative cardiac events and long-term outcome . Anesthesiology . 1995;;83:906-917.
35 +
Fleisher LA, Rosenbaum SH, Nelson AH, Barash PG.  The predictive value of preoperative silent ischemia for postoperative ischemic cardiac events in vascular and non-vascular surgical patients . Am Heart J . 1991;;122:980-986.
36 +
Meinert CL. Clinical Trials: Design, Conduct, and Analysis . New York, NY: Oxford University Press; 1986;:212-213.
37 +
O'Brien PC, Fleming TR.  A multiple testing precedure for clinical trials . Biometrics . 1979;;35: 549-556.
38 +
Hosmer DW, Lemeshow S. Applied Logistic Regression . New York, NY: John Wiley & Sons Inc; 1989;:109-110.
39 +
Breslow MJ, Parker SD, Frank SM, et al.  Determinants of catecholamine and cortisol responses to lower extremity revascularization . Anesthesiology . 1993;;79:1202-1209.
40 +
Lopez M, Sessler DI, Walter K, Emerick T, Ozaki M.  Rate and gender dependence of the sweating, vasoconstriction, and shivering thresholds in humans . Anesthesiology . 1994;;80:780-788.
41 +
Frank SM, Fleisher LA, Olson KF, et al.  Multivariate determinates of early postoperative oxygen consumption: the effects of shivering, core temperature, and gender . Anesthesiology . 1995;;83:241-249.
42 +
Macintyre PE, Pavlin EG, Dwersteg JF.  Effect of meperidine on oxygen consumption, carbon dioxide production, and respiratory gas exchange in postanesthetic shivering . Anesth Analg . 1987;;66: 751-755.
43 +
Kimura S, Cameron JS, Kozlovskis PL, Basseft AL, Myerburg RJ.  Delayed afterdepolarizations and triggered activity induced in feline Purkinje fibers by alpha-adrenergic stimulation in the presence of elevated calcium levels . Circulation . 1984;; 70:1074-1082.
44 +
Hamra M, Rosen MR.  Alpha-adrenergic receptor stimulation during simulated ischemia and reperfusion in canine Purkinje fibers . Circulation . 1988;; 78:1495-1502.
45 +
Sheridan DJ, Penkoske PA, Sobel BE.  Alpha adrenergic contributions to dysrhythmia during myocardial ischemia and reperfusion in cats . J Clin Invest . 1980;;65:161-171.
46 +
Fedida D, Shimoni Y, Giles WR.  A novel effect of norepinephrine on cardiac cells is mediated by alphal-adrenoceptors . Am J Physiol . 1989;;256: H1500-H1504.
47 +
Zipes DP, Miyazaki T.  The autonomic nervous system and the heart: basis for understanding interactions and effects on arrhythmia development . In: Zipes DP, Jalife J, ed. Cardiac Electrophysiology . Philadelphia, Pa: WB Saunders Co; 1990;:312-330.
48 +
Hynson JM, Sessler DI.  Intraoperative warming therapies: a comparison of three devices . J Clin Anesth . 1992;;4:194-199.
49 +
Lennon RL, Hosking MP, Conover MA, Perkins WJ.  Evaluation of a forced-air system for warming hypothermic postoperative patients . Anesth Analg . 1990;;70:424-427.
50 +
Cheng C, Matsukawa T, Sessler DI, et al.  Increasing mean skin temperature linearly reduces the core-temperature thresholds for vasoconstriction and shivering in humans . Anesthesiology . 1995;; 82:1160-1168.
51 +
Smith RC, Leung JM, Keith FM, Merrick S, Mangano DT.  Ventricular dysrhythmias in patients undergoing coronary artery bypass graft surgery: incidence, characteristics, and prognostic importance . Am Heart J . 1992;;123:73-81.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Ozaki M, Kurz A, Sessler DI, et al.  Thermoregulatory thresholds during epidural and spinal anesthesia . Anesthesiology . 1994;;81:282-288.
2 +
Kurz A, Sessler DI, Schroeder M, Kurz M.  Thermoregulatory response thresholds during spinal anesthesia . Anesth Analg . 1993;;77:721-726.
3 +
Sessler DI, Olofsson CI, Rubinstein EH, Beebe JJ.  The thermoregulatory threshold in humans during halothane anesthesia . Anesthesiology . 1988;;68: 836-842.
4 +
Sessler DI, Rubinstein EH, Moayeri A.  Physiologic responses to mild perianesthetic hypothermia in humans . Anesthesiology . 1991;;75:594-610.
5 +
Frank SM, Beattie C, Christopherson R, et al.  Epidural versus general anesthesia, ambient operating room temperature, and patient age as predictors of inadvertent hypothermia . Anesthesiology . 1992;;77:252-257.
6 +
Vaughan MS, Vaughan RW, Cork RC.  Postoperative hypothermia in adults: relationship of age, anesthesia, and shivering in rewarming . Anesth Analg . 1981;;60:746-751.
7 +
Morris RH.  Operating room temperature and the anesthetized, paralyzed patient . Arch Surg . 1971;; 102:95-97.
8 +
Krenzischeck DA, Frank SM, Kelly S.  Forcedair skin-surface warming vs. routine thermal care and core temperature monitoring sites . J Postanesth Nurs . 1995;;10:69-78.
9 +
Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A.  Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty . Lancet . 1996;;347:289-292.
10 +
Kurz A, Sessler DI, Lenhardt R, and the Study of Wound Infection and Temperature Group.  Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization . N Engl J Med . 1996;;334:1209-1215.
11 +
Frank SM, Higgins MS, Breslow MJ, et al.  The catecholamine, cortisol, and hemodynamic responses to mild perioperative hypothermia: a randomized clinical trial . Anesthesiology . 1995;;82:83-93.
12 +
Frank SM, Raja SN, Fleisher LA, Beattie C, Higgins MS, Breslow MJ.  Cardiovascular and adrenergic manifestations of cold stress . In: Zeisberger E, Schonbaum E, Lomax P, eds. Thermal Balance in Health and Disease: Recent Basic Research and Clinical Progress . Basel, Switzerland: Birkhäuser Verlag; 1994;:325-331.
13 +
Frank SM, Higgins MS, Fleisher LA, Sitzmann JV, Raff H, Breslow MJ.  The adrenergic, respiratory, and cardiovascular effects of core cooling in humans . Am J Physiol . 1997;;272:R557-R562.
14 +
Sessler DI.  Perianesthetic thermoregulation and heat balance in humans . FASEB J . 1993;;7:638-644.
15 +
Bay J, Nunn JF, Prys-Roberts C.  Factors influencing arterial P02 during recovery from anaesthesia . Br J Anaesth . 1968;;17:398-407.
16 +
Mangano DT.  Perioperative cardiac morbidity . Anesthesiology . 1990;;72:153-184.
17 +
Slogoff S, Keats AS.  Does chronic treatment with calcium entry blocking drugs reduce perioperative myocardial ischemia? Anesthesiology . 1988;; 68:676-680.
18 +
Lieberman RW, Orkin KF, Jobes DR, Schwartz AJ.  Hemodynamic predictors of myocardial ischemia during halothane anesthesia for coronary artery revascularization . Anesthesiology . 1983;;59:36-41.
19 +
Nelson AH, Fleisher LA, Rosenbaum SH.  The relationship between postoperative anemia and cardiac morbidity in high risk vascular patients in the ICU . Crit Care Med . 1993;;21:860-866.
20 +
Tofler GH, Brezinski DA, Shafer AI, et al.  Concurrent morning increase in platelet aggregability and the risk of myocardial infarction and sudden cardiac death . N Engl J Med . 1987;;316:1514-1518.
21 +
Frank SM, Beattie C, Christopherson R, et al.  Unintentional hypothermia is associated with postoperative myocardial ischemia . Anesthesiology . 1993;;78:468-476.
22 +
Bainton D, Moore F, Sweetnam P.  Temperature and deaths from ischemic heart disease . Br J Prev Soc Med . 1977;;31:49-53.
23 +
Rose G.  Cold weather and ischaemic heart disease . Br J Prev Soc Med . 1966;;20:97-100.
24 +
Lassvik CT, Areskog NH.  Angina in cold environment: reactions to exercise . Br Heart J . 1979;; 42:396-401.
25 +
Epstein SE, Stampfer M, Beiser GD, Goldstein RE, Braunwald E.  Effects of a reduction in environmental temperature on the circulatory response to exercise in man: implications concerning angina pectoris . N Engl J Med . 1969;;280:7-11.
26 +
Juneau M, Johnstone M, Dempsey E, Waters DD.  Exercise-induced myocardial ischemia in a cold environment . Circulation . 1989;;79:1015-1020.
27 +
Mudge GH Jr, Grossman W, Mills RM Jr, Lesch M, Braunwald E.  Reflex increase in coronary vascular resistance in patients with ischemic heart disease . N Engl J Med . 1976;;295:1333-1337.
28 +
Kurz A, Plattner O, Sessler DI, Huemer G, Redl G, Lackner F.  The threshold for thermoregulatory vasoconstriction during nitrous oxide/isoflurane anesthesia is lower in elderly than in young patients . Anesthesiology . 1993;;79:465-469.
29 +
Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau JF, Tateo IM, for the Study of Perioperative Ischemia Research Group.  Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery . N Engl J Med . 1990;;323:1781-1788.
30 +
Hollenberg M, Mangano DT, Browner WS, London MJ, Tubau JF, Tateo IM.  Predictors of postoperative myocardial ischemia in patients undergoing noncardiac surgery . JAMA . 1992;;268:205-209.
31 +
Rubinstein EH, Sessler DI.  Skin-surface temperature gradients correlate with fingertip blood flow in humans . Anesthesiology . 1990;;73:541-545.
32 +
Ramanathan NL.  A new weighting system for mean surface temperature of the human body . J Appl Physiol . 1964;;19:531-533.
33 +
Christopherson R, Beattie C, Frank SM, et al.  Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery . Anesthesiology . 1993;;79:422-434.
34 +
Fleisher LA, Rosenbaum SH, Nelson AH, Jain D, Wackers FJ, Zaret BL.  Preoperative dipyridamole thallium imaging and ambulatory electrocardiographic monitoring as a predictor of perioperative cardiac events and long-term outcome . Anesthesiology . 1995;;83:906-917.
35 +
Fleisher LA, Rosenbaum SH, Nelson AH, Barash PG.  The predictive value of preoperative silent ischemia for postoperative ischemic cardiac events in vascular and non-vascular surgical patients . Am Heart J . 1991;;122:980-986.
36 +
Meinert CL. Clinical Trials: Design, Conduct, and Analysis . New York, NY: Oxford University Press; 1986;:212-213.
37 +
O'Brien PC, Fleming TR.  A multiple testing precedure for clinical trials . Biometrics . 1979;;35: 549-556.
38 +
Hosmer DW, Lemeshow S. Applied Logistic Regression . New York, NY: John Wiley & Sons Inc; 1989;:109-110.
39 +
Breslow MJ, Parker SD, Frank SM, et al.  Determinants of catecholamine and cortisol responses to lower extremity revascularization . Anesthesiology . 1993;;79:1202-1209.
40 +
Lopez M, Sessler DI, Walter K, Emerick T, Ozaki M.  Rate and gender dependence of the sweating, vasoconstriction, and shivering thresholds in humans . Anesthesiology . 1994;;80:780-788.
41 +
Frank SM, Fleisher LA, Olson KF, et al.  Multivariate determinates of early postoperative oxygen consumption: the effects of shivering, core temperature, and gender . Anesthesiology . 1995;;83:241-249.
42 +
Macintyre PE, Pavlin EG, Dwersteg JF.  Effect of meperidine on oxygen consumption, carbon dioxide production, and respiratory gas exchange in postanesthetic shivering . Anesth Analg . 1987;;66: 751-755.
43 +
Kimura S, Cameron JS, Kozlovskis PL, Basseft AL, Myerburg RJ.  Delayed afterdepolarizations and triggered activity induced in feline Purkinje fibers by alpha-adrenergic stimulation in the presence of elevated calcium levels . Circulation . 1984;; 70:1074-1082.
44 +
Hamra M, Rosen MR.  Alpha-adrenergic receptor stimulation during simulated ischemia and reperfusion in canine Purkinje fibers . Circulation . 1988;; 78:1495-1502.
45 +
Sheridan DJ, Penkoske PA, Sobel BE.  Alpha adrenergic contributions to dysrhythmia during myocardial ischemia and reperfusion in cats . J Clin Invest . 1980;;65:161-171.
46 +
Fedida D, Shimoni Y, Giles WR.  A novel effect of norepinephrine on cardiac cells is mediated by alphal-adrenoceptors . Am J Physiol . 1989;;256: H1500-H1504.
47 +
Zipes DP, Miyazaki T.  The autonomic nervous system and the heart: basis for understanding interactions and effects on arrhythmia development . In: Zipes DP, Jalife J, ed. Cardiac Electrophysiology . Philadelphia, Pa: WB Saunders Co; 1990;:312-330.
48 +
Hynson JM, Sessler DI.  Intraoperative warming therapies: a comparison of three devices . J Clin Anesth . 1992;;4:194-199.
49 +
Lennon RL, Hosking MP, Conover MA, Perkins WJ.  Evaluation of a forced-air system for warming hypothermic postoperative patients . Anesth Analg . 1990;;70:424-427.
50 +
Cheng C, Matsukawa T, Sessler DI, et al.  Increasing mean skin temperature linearly reduces the core-temperature thresholds for vasoconstriction and shivering in humans . Anesthesiology . 1995;; 82:1160-1168.
51 +
Smith RC, Leung JM, Keith FM, Merrick S, Mangano DT.  Ventricular dysrhythmias in patients undergoing coronary artery bypass graft surgery: incidence, characteristics, and prognostic importance . Am Heart J . 1992;;123:73-81.

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