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ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 91-96

The effect of body temperature changes on inflammation response and patients’ comfort in patients undergoing laparotomy with general anesthesia


Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Bali, Indonesia

Date of Submission12-Jan-2022
Date of Decision20-Feb-2022
Date of Acceptance28-Feb-2022
Date of Web Publication09-May-2022

Correspondence Address:
Christopher Ryalino
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman Denpasar 80232, Bali
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjoa.bjoa_12_22

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  Abstract 

Background: Surgery and general anesthesia are responsible for disrupting the normal balance between heat production and loss. Inadvertent perioperative hypothermia is a common complication in patients undergoing surgery with general anesthesia. General anesthestic agents are known to cause suppression of thermoregulatory defense mechanisms during general anesthesia, which results in perioperative hypothermia. Hypothermia carries significant various adverse effects; patients’ discomfort and inflammatory stress response are the two variable which will be studied. Materials and Methods: This is a prospective observational analytic cohort study, conducted in the central operating theater of Sanglah Hospital, Bali over a period of 4 months. We included all eligible patients who underwent elective laparotomy and gave consent to the study. Body temperature was measured in three different locations: axilla, tympanic membrane, and nasopharynx, before, during, and after surgery. We measured C-reactive protein (CRP), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (PLR) before and after the surgery. Patients’ comfort level was obtained using the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) scoring system. Results: A total of 60 patients were included. There was a significant increase of inflammatory markers, CRP, PLR, and NLR, before and after the surgery (P < 0.001), as well as reduced body temperature during surgery (P < 0.01); however, there was no significant relationship between the two (P > 0.05). The changes of body temperature significantly affect patients’ comfort level (P < 0.001), whereas room temperature did not show significant impact on patients’ comfort level. On linear regression, there is no significant correlation between body temperature changes and inflammatory response escalation. The increase of CRP was significantly correlated with gender, women, and blood loss, whereas the increase of PLR was related significantly with blood loss and age. Conclusion: Surgery and general anesthesia are causing hypothermia and escalation of inflammatory response. This study result supports prior publication in which both surgery and general anesthesia are the cause of inadvertent perioperative hypothermia; yet, hypothermia does not induce significant rise in all of inflammatory responses measured in this study. It is believed that the major surgery stress response is the cause of significant increase in inflammatory responses.

Keywords: ASHRAE, general anesthesia, hypothermia, inflammation, laparotomy


How to cite this article:
Galag FS, Senapathi TG, Subagiartha M, Sutawan IB, Ryalino C, Pradhana AP. The effect of body temperature changes on inflammation response and patients’ comfort in patients undergoing laparotomy with general anesthesia. Bali J Anaesthesiol 2022;6:91-6

How to cite this URL:
Galag FS, Senapathi TG, Subagiartha M, Sutawan IB, Ryalino C, Pradhana AP. The effect of body temperature changes on inflammation response and patients’ comfort in patients undergoing laparotomy with general anesthesia. Bali J Anaesthesiol [serial online] 2022 [cited 2022 Aug 18];6:91-6. Available from: https://www.bjoaonline.com/text.asp?2022/6/2/91/344879




  Introduction Top


General anesthetic agents are known to cause suppression of thermoregulatory defense mechanisms during general anesthesia, which results in perioperative hypothermia. The incidence of inadvertent perioperative hypothermia due to surgery and general anesthesia is up to 70%. Hypothermia during general anesthesia can be explained on three stages. Phase 1: the redistribution stage, in anesthetic agent-induced vasodilation, core temperature falls while mixing with peripheral blood. Phase 2: the linear stage, in which there is a reduction of metabolic rate by 15–40%. The decrease in heat generated coupled with the increase in heat lost during anesthesia causes a negative heat balance and consequently hypothermia. Heat loss occurs through the mechanism of radiation by 40%, convection 30%, evaporation 25%, and conduction 5%. The drastic changes that occur in the linear phase cause stress in the body which can increase the inflammatory response.[1] Phase 3: the plateau stage, depending on the ambient temperature, the core temperature remains stable, whereas peripheral temperature and total body heat continue to decrease.[2]

Apart from the fact that the anesthetic agent used in general anesthesia causes hypothermia, surgery itself increases the potency of hypothermia. Laparotomy is a major surgery that involves opening abdominal cavity. The prior study has revealed that laparotomy can cause hypothermia due to longer duration of surgery, larger incision required, and the frequent use of peritoneal lavage, which can change organ temperature.[3]

Hypothermia carries significant adverse effects such as patients’ discomfort, increased stress response, shivering, post-operative wound infection or prolonged wound healing, platelet dysfunction, thrombocytopenia, increased intra-operative blood loss, increased post-operative cardiac morbidity, and intracranial hemorrhage events. Therefore, we aimed to find the effect of body temperature changes on inflammation response and patients’ discomfort level.


  Materials and Methods Top


This is a prospective observational analytic cohort study and was approved by the local Ethics Committee on November 17, 2021, no. 2613/UN14.2.2.VII.14/LT/2021, protocol number 2021.02.1.1216. We obtained written informed consent from all patients included in this study. This study was conducted at the central operating theater of Sanglah Hospital, Bali over a period of 4 months. All men aged 18–65 years old, who underwent elective laparotomy with ASA physical status I–III and gave consent to the study, were included. Exclusion criteria were patients with a history of difficult airway and hyperthermia, unstable patients who require intensive care unit monitoring, and patients with certain types of medical condition which limited the ability to the axilla, tympanic membrane, and nasopharynx temperature measurement. Dropout criteria were patients with intraoperative hemodynamic instability, significant blood loss more than 3000 mL, or bleeding grades III to IV.

A standardized general anesthesia protocol was applied to all patients with pre-oxygenation for 3 min, propofol induction (2 mg/kg) and fentanyl (1.5 µg/kg), followed by atracurium (0.5 mg/kg). After intubation, anesthesia was maintained with sevoflurane (1.5 MAC) and atracurium 0.1 mg/kg as maintenance dose every 30 min until the end of the procedure.

Body temperature measurement: Body temperature was taken in three different locations: axilla, using an axillary digital thermometer (Omron MC-245); tympanic membrane, using an Omron Ear Thermometer model TH839S; and nasopharynx, using a Drager nasopharynx probe. Measurement was taken before and during anesthesia, which measured every 15 min during general anesthesia until the end of surgery, and after anesthesia in the recovery room. Operating theater and recovery room ambient temperature was measured. All temperatures measured in Celsius degree.

Inflammatory response measurement: Blood samples were taken to measure inflammatory responses, C-reactive protein (CRP), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (PLR), 1 day prior to surgery and up to 2 days after surgery.

All baseline demographic data were obtained from the patient, such as age, gender, body weight, and height. All perioperative data were also recorded such as ASA physical status, duration of surgery, and blood loss.

The patient comfort level was collected at the recovery room, using ASHRAE Standard 55, 2004. The assessment was taken based on the subjectivity of the patient. Values +3 to +1 are discomfort due to hot temperatures, +3 very hot, +2 warm, +1 slightly warm, whereas values –1 to –3 are discomfort due to cold temperatures, –1 slightly cold, –2 cold, –3 very cold. A value of 0 is defined when the patient is comfortable with the ambient temperature.[4]

All data were analyzed using SPSS 25.0 (IBM Corp., Released 2017, IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY, USA).


  Results Top


A total of 60 patients undergoing laparotomy with general anesthesia were analyzed. In this study population, 80% (n = 48) were females, 20% (n = 12) were males, with the mean age 47.22 ± 11.64, physical status ASA 1 6.7% (n = 4), ASA 2 68.3% (n = 41), and ASA 3 25% (n = 15). All measurement data, inflammatory responses, CRP, PLR, and NRL measurement prior and after the surgery, ambient temperature in the operating theater and recovery room, as well as body temperature measurement in three different locations, prior, during, and after the surgery, can be seen in [Table 1], [Table 2][Table 3].
Table 1: Inflammatory Response Descriptive Data

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Table 2: Ambient temperature descriptive study

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Table 3: Body temperature descriptive study

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[Table 1] and [Table 3] show that there is an increase in CRP, PLR, and NRL after surgery and a decrease in body temperature during surgery. Non-parametric Wilcoxon test was conducted and showed that both changes were statistically significant with P-value less than 0.001. However, Pearson’s correlation test between the two did not reveal any significant relationship (P > 0.005) [Table 4].
Table 4: Pearson’s correlation test between decreased body temperature and increased inflammatory responses after the surgery

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In the perioperative period, patients experience shivering as many as 55% (n = 33). The patient comfort level which was taken after the surgery at the recovery room revealed that as many as 43.4% (n = 26) experienced discomfort, ASHRAE −2, 28.3% (n = 17) experienced mild discomfort, ASHRAE −1, whereas only 28.3% (n = 17) of the patients were comfortable with the room temperature.

The decrease in body temperature significantly causes discomfort in patients (P < 0.001); in contrast, ambient temperature does not (P > 0.005) [Table 5].
Table 5: Comparison between ASHRAE scores, body temperature, and ambient temperature

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The multivariate analysis using linear regression by controlling age, gender, body mass index (BMI), ASA physical status, duration of surgery, blood loss, and room temperature revealed that temperature changes during surgery had no significant effect on increasing inflammatory response, CRP, PLR, NLR after the surgery. The higher post-operative level of CRP was significantly associated with blood loss and gender. The average post-operative CRP level in women was 32.8. Elevation of PLR after the surgery was significantly associated with gender and age. The average post-operative PLR in women was 214.87.


  Discussion Top


Body temperature measurements in this study were carried out at three different locations: the axilla, tympanic membrane, and nasopharynx. Referring to the descriptive data mentioned earlier, there are differences in the average body temperature values measured across the three different locations. The mean axillary body temperature, which is measured on the skin, has a lower value than that of the tympanic membrane and nasopharynx. This difference supports previous studies and existing theory that skin surface temperature is lower than the core body temperature. A previous study by Sahin et al.[5],[6] revealed that axillary temperature assessment showed lower results than the nasopharynx (P < 0.001), whereas temperature measurement of tympanic membrane was not significantly different and more representative with nasopharyngeal temperature. Unfortunately, this study did not carry out statistical tests between the three different temperature measurements.

This study aims to prove the relationship between changes in body temperature with inflammatory response and patients’ comfort level in patients undergoing laparotomy surgery under general anesthesia. Surgery, especially major surgery, and anesthetic agents are the risk factors for hypothermia. Laparotomy is a major surgery that involves opening the abdominal cavity. Laparotomy is known to cause hypothermia, because of the longer duration of surgery, larger incision required, and the frequent use of peritoneal lavage which will change the temperature of the organ.[3] General anesthesia itself causes disruption of normal thermoregulatory control. Almost all general anesthetic agents, which are dose-dependent, can produce a decrease in core temperature which triggers a cold defense, including arteriovenous shunting vasoconstriction and shivering. The main cause of hypothermia in patients under general anesthesia is redistribution of core body heat to the periphery and reduction of the metabolic rate.[7] This has been proven through this present research that there is an incidence of perioperative hypothermia.

Hypothermia is recognized by a decrease in body temperature <36°C and is assessed by the presence of shivering. Shivering is a compensatory mechanism toward hypothermia. Even though the ambient temperature and skin temperature change, the core temperature usually does not change due to the extraordinary thermoregulation. The core body temperature was maintained relatively constant between 36.6°C and 37°C. More than half of the samples experienced chills, which means that the patients were hypothermic, so the reflection that needs to be done is to prioritize the prevention of hypothermia, by pre-warming 1–2 h before anesthesia, especially in patients with longer surgery, more than 60 min; other preventive strategies include warmed blanket, warmed intravenous fluids or blood, and controlling the ambient temperature, at least 21°C for adult patients and 24°C for pediatric patients.[8]

The operating room temperature in this study was controlled with an average of 20.8 ± 0.65°C (range 20–22°C) and humidity level of 72.7 ± 6.58, yet it is still below the reference value stated earlier; therefore, we should observe the operating theater room temperature more closely.

Inadvertent intraoperative hypothermia was statistically significant in this study. The level of inflammatory response measured by CRP, PLR, and NLR also showed a significant increase after the surgery. However, there is no significant relationship between the two. These relationships remain unchanged even after adjusting for age, gender, BMI, ASA physical status, duration of operation, blood loss, and room temperature, using linear regression. This proves that surgical stress is the main culprit in increasing inflammatory response after the surgery. Major surgery is an invasive procedure that causes a stress response.[9] The magnitude of the surgical stress response is related to the type of surgery, one of which is laparotomy surgery.[3] General anesthetic agents also contribute to increasing the inflammatory response. Propofol, which is often used in general anesthesia, is associated with systemic inflammatory response modulation after the major surgery.[9]

Decrease in body temperature was significantly associated with patients’ comfort. In contrast, room temperature does not significantly affect patients’ comfort, so it can be concluded that ambient temperature can indirectly affect changes in body temperature, which causes discomfort.

We found that higher CRP level after the surgery was significantly associated with the amount of bleeding and gender. A greater amount of bleeding indicates organ damage or a greater stress response so that it is in line with an increased inflammatory response. Previous studies comparing female and male CRP levels have various results. Some showed differences between the sexes, which is higher in women,[10] whereas several studies showed no difference.[11],[12],[13] This inconsistent result is due to the fluctuations of CRP levels in women during the menstrual cycle.[14] CRP levels in women reach the highest and most variable during menstruation. The increase in CRP was significantly inversely related to endogenous estradiol and positively associated with the progesterone luteal phase. In contrast to the endogenous hormones, exogenous estrogen or estrogen and progesterone significantly increase CRP levels.[14] In this study, although a significant relationship was found among increased post-operative CRP levels in women, we cannot deny that these results can be influenced by other factors, such as patients’ cycle during surgery and the use of hormone therapy in the patients, all of which are not recorded in this study.

The higher PLR level after surgery was significantly associated with gender, women, and age. This is understandable because women basically have higher inflammation factor. Various previous studies have shown results in which normal PLR values are higher in women than in men. An explanation for those results is that menstruating women have lower levels of iron, which stimulate platelet production.[15] In addition, differences in hormones such as estrogen levels also play a role; a prior study conducted in mice showed that estrogen can increase platelet formation.[16]

As people get older, they tend to have a higher tendency of infection or inflammation, which can explain the relationship of age and higher PLR and CRP levels after surgery. On the contrary, prior research revealed that the PLR level is higher in young and adult ages, but not in old age; this is associated with a decrease in hematopoietic stem cells which will lead to a reduction in platelet formation in elderly.[15] This explanation contradicts with the results of this study; nonetheless, the mean age of this study sample was 47.22 ± 11.64, so it can be believed that the majority of patients still had normal hematopoiesis[15] NLR is widely used for numerous medical conditions, and it plays a certain role as the prognostic marker for cancer, as well as its relationship with several chronic conditions.[17],[18] In spite of its use for stratification of cancer and several chronic conditions, NLR has raised its voice as a promising index of acute inflammatory stress response, such as surgery, which is stated in this study.

All three different inflammatory markers are a strong indicator for surgical stress and inflammatory response, despite the fact that it is unreliable for hypothermia.

We recognize several weaknesses in this study such as the non-blinded temperature measurement in three different locations and the subjectivity of patients’ comfort scoring, all of which can cause bias.


  Conclusion Top


Major surgery and general anesthesia cause a significant increase in CRP, PLR, and NLR, but a significant decrease in body temperature; yet, there was no significant relationship between the two. The decrease in body temperature significantly causes discomfort in patients, whereas ambient temperature does not. Women significantly have higher CRP and PLR levels after the surgery. Elevation of CRP after the surgery significantly correlated with blood loss, whereas elevation of PLR after the surgery significantly correlated with age.

It is known that general anesthetic agents inhibit normal thermoregulatory control in a dose-dependent fashion; hence, further studies to analyze between anesthetic doses and hypothermia should be taken into serious consideration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Hwang RL, Lin TP, Cheng MJ, Chien JH. Patient thermal comfort requirement for hospital environments in Taiwan. Build Environ 2007;42:2980-7. Available from: https://researchoutput.ncku.edu.tw/en/publications/patient-thermal-comfort-requirement-for-hospital-environments-in-.  Back to cited text no. 4
    
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Kim HJ, Roychoudhury P, Lohia S, Kim JS, Kim HT, Ro YJ, et al. Comparison of general and spinal anaesthesia on systemic inflammatory response in patients undergoing total knee arthroplasty: A propensity score matching analysis. Medicina (Kaunas)2021;57:1250.  Back to cited text no. 9
    
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Khera A, McGuire DK, Murphy SA, Stanek HG, Das SR, Vongpatanasin W, et al. Race and gender differences in C-reactive protein levels. J Am Coll Cardiol 2005;46:464-9.  Back to cited text no. 10
    
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Imhof A, Fröhlich M, Loewel H, Helbecque N, Woodward M, Amouyel P, et al. Distributions of C-reactive protein measured by high-sensitivity assays in apparently healthy men and women from different populations in Europe. Clin Chem 2003;49:669-72.  Back to cited text no. 11
    
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Gaskins AJ, Wilchesky M, Mumford SL, Whitcomb BW, Browne RW, Wactawski-Wende J, et al. Endogenous reproductive hormones and C-reactive protein across the menstrual cycle: The BioCycle study. Am J Epidemiol 2012;175:423-31.  Back to cited text no. 14
    
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Wu L, Zou S, Wang C, Tan X, Yu M. Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratio in Chinese Han population from Chaoshan region in South China. BMC Cardiovasc Disord 2019;19:125.  Back to cited text no. 15
    
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Nagata Y, Yoshikawa J, Hashimoto A, Yamamoto M, Payne AH, Todokoro K. Proplatelet formation of megakaryocytes is triggered by autocrine-synthesized estradiol. Genes Dev 2003;17: 2864-9.  Back to cited text no. 16
    
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Imtiaz F, Shafique K, Mirza SS, Ayoob Z, Vart P, Rao S. Neutrophil lymphocyte ratio as a measure of systemic inflammation in prevalent chronic diseases in Asian population. Int Arch Med 2012;5:2.  Back to cited text no. 17
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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