Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2011 / Vol 1 | Issue 2 73

Efficacy of intravenous fluid warming for

maintenance of core temperature during lower
segment cesarean section under spinal anesthesia
ABS T R AC T
Introduction: Maintenance of body temperature of obstetrical patients undergoing cesarean
section is complicated by a variety of factors including heat loss to atmosphere, infusion of
fuids at room temperature, disruption of thermoregulatory mechanisms by epidural or spinal
anesthesia and redistribution hypothermia. Infusion of warm fuids is an important method of
heat conservation. Hence, we evaluated the effcacy of intravenous fuid warming in preventing
hypothermia by observing the change in core temperature with intravenous fuids at room
temperature (22C and 39C) in patients undergoing lower segment cesarean section under
spinal anesthesia.
Materials and Methods: Sixty-four patients belonging to ASA grade I and II were randomly
allocated to either of the two groups. Group I received intravenous fuids at room temperature
(22C) and group II received intravenous fuids via fuid warmer (39C). Core temperature was
recorded at every 1 min for the frst 5 min, followed by 10 min till the end of surgery using a
tympanic thermometer.
Results: The mean decrease in core temperature in group I was 2.184 0.413 and 1.934
0.439 in group II. The comparison of group I and II showed a statistically signifcant difference
in mean core temperatures at times 5, 50, 60, 70, 80 and 90 min and immediately on arrival
in the recovery room. A lower incidence of shivering was seen in group II patients, but the
difference in the two groups was not statistically signifcant.
Conclusion: Infusion of warm intravenous fuids resulted in a lesser degree of fall in core
temperature, thereby providing a signifcant temperature advantage; however, this did not
translate to prevention of postoperative shivering.
Key words: Hypothermia, intravenous fuid warming, shivering, spinal anesthesia
Original Article
Parveen Goyal, Sandeep Kundra,
Shruti Sharma, Anju Grewal,
Tej K. Kaul, M. Rupinder Singh
Department of Anesthesiology,
Dayanand Medical College and
Hospital, Ludhiana, Punjab, India
Address for correspondence:
Dr. Sandeep Kundra, Department of
Anesthesiology, Dayanand Medical
College and Hospital, Ludhiana 141 001,
Punjab, India.
E-mail: sandeepkundra@redifmail.com
INTRODUCTION
H
ypothermia, defned as core temperature below 36C,
during spinal anesthesia is certainly far more common
than generally appreciated. The maintenance of body
temperature of obstetrical patients undergoing cesarean section
is complicated by a variety of factors, including heat loss to
atmosphere due to cool operating room, the infusion of fuids
at operating room temperature, disruption of the normally
coordinated thermoregulatory mechanisms by epidural/
spinal anesthesia and redistribution hypothermia.
[1]
Neuraxial
anesthesia impairs central autonomic thermoregulatory
control,
[1]
possibly by increasing apparent (as opposed to actual)
leg skin temperature.
[2]
Core temperatures 12C below normal
have been associated with adverse outcomes, such as shivering,
an increased incidence of surgical wound infection, prolonged
hospitalization, morbid cardiac events, increased blood loss,
allogeneic transfusion requirements, etc.
[3,4]
Apart from the
distress hypothermia causes to the patients, shivering produces
undesirable physiological consequences such as raised oxygen
consumption and hypoxemia, increased cardiac work, raised
carbon dioxide production, lactic acidosis and lower mixed
venous oxygen saturation and decreases the motherbaby
bonding in the postoperative period.
[5]
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DOI:
10.4103/2249-4472.93990
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74 Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2011 / Vol 1 | Issue 2
Among the many methods to maintain body temperature in
the operation theater and recovery room, the administration
of warm intravenous fluids (I.V.) seems to be easy and
physiological. Patients who receive operating room temperature
intravenous fuids had a higher incidence of shivering than
patients who were given warm fuids.
[5,6]
It has been shown that
rapid infusion of warm I.V. fuids may alter the rate of shivering,
depending on the temperature of the fuids.
[7]
Few studies have,
however, reported that warming I.V. fuids did not prevent
hypothermia in term parturients undergoing elective cesarean
section.
[8]
In view of the conficting reports by various authors,
we evaluated the efcacy of I.V. fuid warming in maintenance
of core temperature in patients undergoing lower segment
cesarean section (LSCS) under spinal anesthesia.
MATERIALS AND METHODS
Te study was conducted afer approval by the Hospital Ethical
Committee on 64 obstetrical patients belonging to ASA grade
I and II, scheduled for elective LSCS under spinal anesthesia.
A written informed consent was taken from all patients prior
to inclusion in the study. Patients were randomly divided using
computer-generated random numbers into two groups I and
II of 32 patients each.
Group I: Patients were infused I.V. fuids at operating room
temperature (22C). (I.V. fuid containers having been kept in
the operation theater at least 1 h before start of surgery and
also ensuring that the surface temperature of the fuid container
was as required.)
Group II: Patients were infused with warm I.V. fuids (39C) by
using a fuid warmer (Astotherm plus AP220, FUTUREMED).
A thorough preanesthetic check up was carried out on all
patients as per standard protocols. Patients with preoperative
temperature >38C or <36C; patients with impacted wax,
external/middle ear infection, tympanic membrane perforation,
urinary tract infection, diabetic autonomic neuropathy or any
neurological disease, emergency surgery; and patients with
indwelling epidural catheter for labor analgesia were excluded
from the study.
All patients received premedication in the form of tablet
Ranitidine 150 mg the night before surgery and 150 mg in the
morning of the surgery with a sip of water.
Baseline blood pressure, pulse rate, SpO
2
and core temperature
(tympanic membrane) were recorded preoperatively in all
patients. Te operating room temperature was also recorded at
this time. Te operation room temperatures remained between
21 and 22 degrees centigrade throughout the surgery, which
is a norm in our hospital settings. All patients were preloaded
with 0.9% sodium chloride 10 mL/kg transfused within 30
min before establishment of the subarachnoid block. Te
temperature of the infusing fuid depended on the group of the
patient (either 22C in group I or 39C in group II).
Subarachnoid block was achieved under strict aseptic
precautions in the lef lateral position using a 26 G (Quinckes)
needle introduced in the L
3
-L
4
intervertebral space. Afer
obtaining a free fow of cerebrospinal fuid, bupivacaine 0.5%
(heavy) 2.5 mL was injected in the subarachnoid space. Te
patient was made supine immediately and surgery commenced
afer achieving block level of T6. During the intraoperative
period, patients were completely covered in surgical drapes.
Vital parameters like NIBP, HR and SpO
2
were recorded at
every 1 min for the initial 5 min, followed by every 10 min
till the end of surgery. All patients received I.V. infusion at
temperatures depending on the group allocation, at the rate
of 10 mL/kg/h of crystalloid solution.
Core temperature (tympanic membrane) was recorded at
every 1 min for the frst 5 min followed by 10 min till the end
of surgery using a tympanic thermometer. Room temperature
was also recorded at the start of surgery, afer half an hour
and afer the end of surgery. Afer completion of surgery,
patients were shifed to the recovery room. Core temperature
was noted on arrival, afer 30 min, 60 min and 90 min in the
recovery room. Presence or absence of shivering and number
and type of interventions for treating the shivering (radiant
heat, intravenous pethidine 12.5 mg given when patient either
complained of shivering or cold distress) were noted. Patients
were discharged from recovery when the modifed Alredttes
score was 9 or more, patients were able to fex their foot and
had proprioception in the great toe.
[9]
Time to discharge was
also noted. All observations were recorded and subsequently
tabulated and analyzed using Students t-test and z-test.
RESULTS
Demographic profile (age, height, weight and body mass
index) of all patients in both groups I and II was statistically
comparable [Table 1].
In groups I and II, the baseline mean core temperature was
37.83 0.144C and 37.89 0.113C, respectively. Tere was
no statistical diference between the two groups. Tere was a
decrease in the core temperature thereafer. Te decrease in
core temperature from baseline (0 min) to the end of surgery
(90 min) was statistically signifcant, with a P-value <0.01 for
both groups I and II [Figure 1].
Comparison of core temperature at 5, 50, 60, 70, 80 and 90 min
Goyal, et al.: Effcacy of IV fuid warming for core temperature maintenance
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Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2011 / Vol 1 | Issue 2 75
revealed statistically signifcant diferences between groups I
and II. Te diference in the decrease in mean core temperature
between the two groups was also found to be statistically
signifcant (P < 0.01). In group I, 24 of 32 patients had a core
temperature <36C while in group II, only 13 of 32 patients had
a core temperature <36C at the time of arrival in the recovery
room, and this diference in number of patients was found to
be statistically signifcant (P < 0.05).
On arrival in the recovery room, the mean core temperature of
group I patients was signifcantly less as compared with group II
(P < 0.05) (35.49 0.414C versus 35.77 0.456C). Similarly,
at 30 min afer arrival in the recovery room, the mean core
temperature of group I patients was 35.47 0.385C and that
of group II patients was 35.99 0.449C, which was statistically
signifcant between the two groups. Te mean core temperature
comparison was statistically nonsignifcant afer 60 and 90 min.
In group I, shivering was present in 10 patients and in group II,
shivering was present in eight patients, but this diference was
statistically not signifcant [Table 2]. In group I, intervention
was needed to be carried out in 10 patients and in group II,
intervention was needed in eight patients [Table 3]. Te number
of interventions needed was signifcantly higher in group I in
comparison with group II. Te mean discharge times in group I
was 105.50 9.48 min and in group II was 107.30 9.21 min. In
both the groups, there was no statistically signifcant diference
in discharge time from recovery room [Table 4].
DISCUSSION
Regional anesthesia causes redistribution of heat from the core
to the periphery secondary to peripheral vasodilatation.
[10]
It
also decreases the shivering threshold by 0.6C, triggering
vasoconstriction and shivering (above the level of block),
[11]

and, by blocking the autonomic control to the afected region,
prevents vasoconstriction and shivering in the region of the
block.
[12]
Tese efects predispose patients to the development
of hypothermia during regional anesthesia, resulting in
postoperative shivering, increased oxygen consumption and
may also be a causative factor for neonatal hypothermia.
[13,14]

Furthermore, neuraxial anesthesia also impairs behavioral
thermoregulation with the result that patients ofen do not
consciously perceive that they are hypothermic.
[14]
Various methods have been tried for prevention of hypothermia
in cesarean patients with variable success rate. The most
important methods for preventing preoperative hypothermia
are intravenous fuid warming and forced-air heating.
[15]
Each
liter of fuid infused at ambient temperature decreases the mean
Table 1: Dermographic prole of patients
Variable Group I (n = 32) Group II (n = 32) P-value
Age 27.16 4.30 26.84 5.77 >0.10 (NS)
Height 156.33 1.92 156.33 1.96 >0.10 (NS)
Weight 64.06 5.76 66.60 7.09 >0.10 (NS)
BMI 26.21 2.20 27.23 2.75 >0.10 (NS)
Group 1: Patients receiving intravenous uids at ambient temperature Group 2:
Patients receiving warm intravenous uids
Table 2: Incidence of shivering
Shivering Group I (n = 32) Group II (n = 32)
No. % No. %
Yes 10 31.25 8 25.00
No 22 68.75 24 75.00
P-value NS, Z-value 0.63
Table 3: Distribution according to intervention done
(radiant heat, meperidine) to prevent shivering
Intervention done Group I (n = 32) Group II (n = 32)
Radiant heat, meperidine No. % No. %
Yes 10 31.25 8 25.00
No 22 68.75 24 75.00
Z-value 0.63, P-value NS
Table 4: Distribution according to discharge time from
recovery room
Discharge time from
recovery room (min)
Group I (n = 32) Group II (n = 32)
No. % No. %
96101 17 53.13 14 43.75
101107 5 15.62 3 9.38
107113 0 0 7 21.88
113119 4 12.50 1 3.12
119125 6 18.75 7 21.88
Mean SD 105.50 9.48 107.30 9.21
t-value 0.77, P-value >0.10 (non signicant)
Goyal, et al.: Effcacy of IV fuid warming for core temperature maintenance
Figure 1: Trends in mean core temperature (C) in the two study groups
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76 Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2011 / Vol 1 | Issue 2
body temperature by 0.25C in an average-sized patient.
[16]
Administration of room temperature intravenous fluids
contributes to hypothermia; hence, infusion of warm fuids has
been evaluated as an important method of heat conservation.
Warm intravenous fuids can increase the core temperature
by 0.50.7C and lower the incidence of hypothermia.
[3,17]
Te
results of our study make it evident that fuid warming resulted
in a lesser fall of core temperature as compared with fuids given
at operating room temperature. In the present study, the mean
core temperature of patients in group 2 was higher than that of
patients in group 2 at arrival and at 30 min. Warm intravenous
fuids thus contributed to less-signifcant heat losses and hence
attainment of the plateau phase of thermoregulatory responses.
Te incidence of shivering in the two groups was not statistically
signifcant. Similarly, no statistically signifcant diferences in
discharge times from recovery room were noted.
Te results of our study are in concordance with the results
obtained in the study conducted by Smith et al., who
demonstrated that outpatients receiving warmed intravenous
fuids were more likely to be normothermic at the end of
surgery and on arrival in the recovery room than those who
received fluids at operating room temperature. However,
neither hypothermia nor postoperative shivering delayed
discharge afer these ambulatory surgical procedures.
[17]
Tey
also studied the efcacy of intravenous fuid warming in patients
undergoing cesarean sections under regional anesthesia and
found that the fall in core temperature was less in patients who
received warmed intravenous fuids (-0.8 0.1) as compared
with patients who received intravenous fluids at ambient
temperature (-1.2 0.1). Te infusion of warm fuids resulted
in a 0.40.5C temperature advantage as compared with room
temperature fuids in their study.
[6]
Yokoyama et al. also confirmed this higher temperature
advantage in patients receiving prewarmed fuids. In addition,
APGAR scores in the neonate and umbilical pH were higher in
patients receiving warmed intravenous fuids, suggesting better
neonatal outcomes as well.
[18]
Similar results were obtained by
Aglio et al.,
[6]
wherein the

authors observed that the infusion of
warm fuids during cesarean delivery and in labor resulted in
less fall in temperature and a signifcantly reduced incidence
of shivering as compared with patients receiving intravenous
infusions at room temperature. Tis advantage of a reduction
in incidence of shivering was however not observed in our
study. Post spinal shivering is a poorly understood entity
with multiple possible etiologies. Neuraxial anesthesia per se
leads to a reduction in shivering threshold.
[14]
Te consequent
hypothermia occurring during neuraxial anesthesia is attributed
to multifactorial causes, with redistribution hypothermia being
a leading cause.
[14]
Tis could have accounted to variance in
the results of our study. Furthermore, Aglio et al. evaluated
too small a study group, which could have led to a bias in their
study. However, large sample sized randomized controlled trials
are needed to further delineate the advantage of intravenous
fuid warming to postoperative normothermia and shivering.
In conclusion, infusion of warm intravenous fuids to parturients
undergoing cesarean section under regional anesthesia
decreases the degree of hypothermia and is associated with
a 0.25C temperature advantage compared with intravenous
fuids infused at ambient temperature of the operating room.
However, it was not efective to prevent shivering and to
decrease time to discharge from recovery room.
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Cite this article as: Goyal P, Kundra S, Sharma S, Grewal A, Kaul TK, Singh
MR. Effcacy of intravenous fuid warming for maintenance of core temperature
during lower segment cesarean section under spinal anesthesia. J Obstet
Anaesth Crit Care 2011;1:73-7.
Source of Support: Nil, Confict of Interest: None declared.
Goyal, et al.: Effcacy of IV fuid warming for core temperature maintenance
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