This document discusses thermoregulation in newborns and the importance of maintaining normal body temperature. It outlines the key mechanisms newborns use for heat production and heat loss, and how external factors like environment temperature and humidity can impact thermoregulation. The document also discusses hypothermia risks in newborns from conditions that impair thermoregulation and provides best practices for preventing perioperative hypothermia in newborns through measures like prewarming, warm operating rooms, and skin-to-skin contact. Complications of hypothermia include increased bleeding, infection risk, and prolonged recovery.
Thermal care is central to reducing morbidity and mortality in newborns. Thermoregulation is the ability to balance heat production and heat loss in order to maintain body temperature within a certain normal range. The average “normal” axillary temperature is considered to be 37°C
neonatal hypothermia is a very emergency condition. if we identify this in early stage we can save the life of neonate. all should know about the maintaining the temperature if the neonate is in our home.
Thermal care is central to reducing morbidity and mortality in newborns. Thermoregulation is the ability to balance heat production and heat loss in order to maintain body temperature within a certain normal range. The average “normal” axillary temperature is considered to be 37°C
neonatal hypothermia is a very emergency condition. if we identify this in early stage we can save the life of neonate. all should know about the maintaining the temperature if the neonate is in our home.
Hypothermia occurs when the newborn’s temperature drops below 36.3°C.
The smaller or more premature the newborn is, the greater the risk of heat loss. When heat loss exceeds the newborn’s ability to produce heat, its body temperature drops below the normal range and the newborn becomes hypothermic.
Early prevention measures are vital.
A developmental anomaly is a broad term used to define conditions which are present at conception or occur before the end of pregnancy. In the case of cerebral palsy, a small number also occur after birth. this is also a birth defect.
Newborn Care: Temperature control and hypothermiaSaide OER Africa
Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents
CLINICAL TEACHING ON BUBBLE CPAP: Introduction, Definition, History of development, Physiology of Bubble CPAP, Principle, Patient interface, equipments for bubble CPAP, indication and contraindication for bubble CPAP, essential of CPAP, CPAP machine, bubble cpap machine application, setting pressure, FiO2, oxygen flow, Monitoring adequacy and complications of bubble CPAP, Monitoring infant condition, weaning for Bubble CPAP, CPAP Failure, complications related to CPAP, Preventing complications, Nursing Care.
This slides contain detailed description of radiant warmer used in hospital setting, various modes , alarms, do's and don't of radiant warmer and nursing care management for the baby under radiant warmer
Thermoregulation in neonates, or newborn infants, is a critical aspect of their care and well-being. Neonates have limited ability to regulate their body temperature compared to older children and adults. They are highly susceptible to heat loss and have a greater risk of developing hypothermia, which can have detrimental effects on their health.
Several factors contribute to the challenges of thermoregulation in neonates. Firstly, their body surface area-to-weight ratio is higher than that of adults, making them more vulnerable to heat loss. Additionally, neonates have thinner skin and less insulating subcutaneous fat, reducing their ability to retain heat. Their immature nervous systems and limited ability to shiver further complicate their temperature regulation capabilities.
To support thermoregulation in neonates, various measures are taken in clinical settings. Immediately after birth, drying the baby and placing them under a radiant warmer or on a warm, dry surface helps to prevent heat loss. Skin-to-skin contact with the mother, also known as kangaroo care, provides warmth and promotes bonding while stabilizing the infant's temperature.
The use of warm clothing, hats, and swaddling blankets assists in reducing heat loss through evaporation and conduction. Incubators and heated cribs maintain a controlled environment to prevent temperature fluctuations. Additionally, monitoring the infant's temperature regularly and adjusting the ambient temperature as needed are crucial for maintaining their thermal stability.
Preventing overheating is equally important, as excessive warmth can lead to hyperthermia. It is essential to avoid excessive clothing or covering that could cause the baby to overheat.
Ensuring a suitable ambient temperature, promoting skin-to-skin contact, and providing appropriate clothing and thermal support are vital components of neonatal care to maintain a stable body temperature. By carefully managing thermoregulation, healthcare professionals can help optimize the well-being and development of newborn infants.
Hypothermia occurs when the newborn’s temperature drops below 36.3°C.
The smaller or more premature the newborn is, the greater the risk of heat loss. When heat loss exceeds the newborn’s ability to produce heat, its body temperature drops below the normal range and the newborn becomes hypothermic.
Early prevention measures are vital.
A developmental anomaly is a broad term used to define conditions which are present at conception or occur before the end of pregnancy. In the case of cerebral palsy, a small number also occur after birth. this is also a birth defect.
Newborn Care: Temperature control and hypothermiaSaide OER Africa
Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents
CLINICAL TEACHING ON BUBBLE CPAP: Introduction, Definition, History of development, Physiology of Bubble CPAP, Principle, Patient interface, equipments for bubble CPAP, indication and contraindication for bubble CPAP, essential of CPAP, CPAP machine, bubble cpap machine application, setting pressure, FiO2, oxygen flow, Monitoring adequacy and complications of bubble CPAP, Monitoring infant condition, weaning for Bubble CPAP, CPAP Failure, complications related to CPAP, Preventing complications, Nursing Care.
This slides contain detailed description of radiant warmer used in hospital setting, various modes , alarms, do's and don't of radiant warmer and nursing care management for the baby under radiant warmer
Thermoregulation in neonates, or newborn infants, is a critical aspect of their care and well-being. Neonates have limited ability to regulate their body temperature compared to older children and adults. They are highly susceptible to heat loss and have a greater risk of developing hypothermia, which can have detrimental effects on their health.
Several factors contribute to the challenges of thermoregulation in neonates. Firstly, their body surface area-to-weight ratio is higher than that of adults, making them more vulnerable to heat loss. Additionally, neonates have thinner skin and less insulating subcutaneous fat, reducing their ability to retain heat. Their immature nervous systems and limited ability to shiver further complicate their temperature regulation capabilities.
To support thermoregulation in neonates, various measures are taken in clinical settings. Immediately after birth, drying the baby and placing them under a radiant warmer or on a warm, dry surface helps to prevent heat loss. Skin-to-skin contact with the mother, also known as kangaroo care, provides warmth and promotes bonding while stabilizing the infant's temperature.
The use of warm clothing, hats, and swaddling blankets assists in reducing heat loss through evaporation and conduction. Incubators and heated cribs maintain a controlled environment to prevent temperature fluctuations. Additionally, monitoring the infant's temperature regularly and adjusting the ambient temperature as needed are crucial for maintaining their thermal stability.
Preventing overheating is equally important, as excessive warmth can lead to hyperthermia. It is essential to avoid excessive clothing or covering that could cause the baby to overheat.
Ensuring a suitable ambient temperature, promoting skin-to-skin contact, and providing appropriate clothing and thermal support are vital components of neonatal care to maintain a stable body temperature. By carefully managing thermoregulation, healthcare professionals can help optimize the well-being and development of newborn infants.
Temperature is the balance between the heat production and heat loss.
A brief outline of diffrent aspects regarding body temperature is discussed here under following headings
*Normal body temperature regulation
*Fever of unknown origin
*Hyperthermia
*Hypothermia
*Frost bite
NEONATAL HYPOTHERMIA PAEDIATRICS BY DR. PARTHASARATHYSamDilipPrasanth1
The World Health Organization (WHO) defines
neonatal hypothermia as an axillary temperature
below 36.5°C (97.7°F) among newborns aged
below 28 days.
Normal axillary temperature is
36.5–37.5°C
Severity Of Hypothermia
1)Mild hypothermia/cold stress 36.0–36.4°C
2)Moderate hypothermia 32.0–35.9°C
3)Severe hypothermia <32°C.
It is an environmental temperature at which the newborn has minimal
rates of oxygen consumption and expends the least energy to maintain
its temperature is needed.
Mechanism Of Heat Production in
Newborn
1)Nonshivering thermogenesis—occurs by utilizing brown fat in
newborns. Thermoreceptors on sensing a low temperature result in
elevated sympathetic output and this stimulates the beta-adrenergic
receptors in the brown fat increasing cAMP. This results in
increased metabolism and increases heat production.
2) Increased metabolic activity—the brain, heart, and liver produce
metabolic energy by oxidative metabolism of glucose, fat, and
protein.
3)Peripheral vasoconstriction—reduces blood flow to the skin and
decreases loss of heat.
MECHANISM OF HEAT LOSS IN NEWBORN
Evaporation
Radiation
Due to the
evaporation of
amniotic fluid
from skin surface
Conduction
By coming in
contact with
cold objects
such as cloth
and weighing
tray
Convection
Convection by
air currents
where cold air
replaces warm
air around baby
due
to open windows,
fans, etc.
Radiation to
colder solid
objects in
vicinity-like
walls
Risk Factors
PRETERM,
LBW,IUGR,Asphyxia
Congenital
Abdominal Wall
defects
Low delivery room
temperature, Bathing
the baby after
delivery
Removal of vernix
caseosa, Reduced
contact with mother
Delayed initiation of
breastfeed
Surgical procedures
PREVENTION OF HYPOTHERMIA IN VARIOUS
SETUPS
Memories flashed across my
mind as I came
across the first photo
of myself as a little
baby..
In delivery room and operation theater:
• Follow the 10 steps of “warm chain” recommended by the WHO.
Draught free and warm delivery room temperature of 25–28°C.
Radiant warmer to be prewarmed along with all the linen and clothes/cap before
delivery.
Cap prevents significant heat loss in preterm as well as in term infants. Remove wet towel.
Baby is placed directly on the mother’s abdomen or chest after delivery in both vaginal
and cesarean delivery.
Provide warmth by skin-to-skin contact after drying with a warm and dry linen if baby
is doing well.
Breastfeeding can be started immediately and the baby and the mother are covered
with a warm blanket. Delay bathing. No bathing in the hospital.
Resuscitation, if required, should be done under the radiant warmer and heated
humidified gases to be used if oxygen or positive pressure ventilation is required.
Prewarm medications and intravenous (IV) fluid, if required.
During surgery, abdominal organ coverage reduces the incidence of hypothermia.
Additional measures for very preterm infants (who are more prone to hypothermia due
to greater surface-to-mass ratio and lesser brown fat):
In the NICU:
• Use servocontrolled warmer or
Perinatal asphyxia is an insult to the fetus or the newborn due to lack of oxygen (hypoxia) and or a lack of perfusion (ischemia) to various organs. Hypoxia ischemia remains a significant cause of neonatal mortality and morbidity and adverse neurodevelopmental outcome. Therapeutic hypothermia found to improve neurodevelopmental outcome in asphyxiated babies.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. INTRODUCTION
THERMOREGULATION
◦ HEAT PRODUCTION
◦ HEAT LOSS
◦ Thermoregulation and Anesthesia
HYPOTHERMIA
PERIOPERATIVE HYPOTHERMIA PREVENTIVE MEASURES
COMPLICATION OF PERIOPERATIVE HYPOTHERMIA
REFERENCES
3. Maintaining a neutral thermal environment is one of
the key physiologic challenges that a newborn must
face after delivery
In early 1900s
◦ Realized warm environment is essential
Last decades
◦ Improved care of newborns in developed world
◦ Still common problem in developing countries
Thermal care is central to reducing morbidity and
mortality in newborns.
4. Thermoregulation
◦ The ability to balance heat production and heat loss in
order to maintain body temperature within a certain
normal range(36.5-37.5ºc)
Goals
◦ Maximize metabolic efficiency
◦ Reduce oxygen use
◦ Protect enzyme function
◦ Reduce calorie expenditure
5. Thermoneutral zone:
◦ The range of ambient temperature required for the
infant (for each gestational age and weight) to keep a
normal body temperature and a minimal basal
metabolic rate
Extreme environmental temperature variations
◦ overcome this effective thermoregulatory function
lead to heat- or cold-related illnesses
7. Heat loss occurs from
energy needed to vaporize
liquids
◦ skin,lung,mucosa and serosa
Accounts major heat
loss…50%
Depends on
◦ The exposed body surface area
◦ Relative humidity of the
ambient air
◦ The speed of the wind
8. Heat loss to the nearby cold
objects with out physical
contact
Major source of heat loss in
most surgical patients(60%)
Depends on
◦ The T differences
◦ The body exposed to the
environment
◦ Distance between two surfaces
◦ The skin blood flow
9. Heat transfer from warm to
cool objects with direct contact
Accounts 5%
Depends on
◦ Area of body exposed
◦ Relative difference in temperature
◦ Thermal conductivity
10. Special type of conduction heat
loss through moving gases
Accounts 15%
Second most common heat loss
in anesthetized pt
Depends on
◦ The temperature difference
◦ The speed of air
Proportional to the square root of air
speed
11. Cold Items on Bed
Cold Walls
Cold Room Temp.
Radiation
Cold Blankets
Cold X-ray plates
Cold Scale
Conduction
Passing Traffic
Oxygen left on
Bed Near Air Vent
Convection
Tachypnea
Bath
Wet Diaper
Evaporation
Baby
d
12. During pregnancy
◦ Maternal mechanisms maintain the intrauterine
temperature
After birth
◦ The newborn must adapt to their environment by the
metabolic production of heat
Primary source of heat in the newborn
◦ Non -shivering thermogenesis
◦ Metabolic processes
◦ Voluntary muscle activity
◦ Involuntary muscle activity (shivering thermogenesis)??
◦ Peripheral vasoconstriction
13. Metabolism of brown adipose tissue
◦ Initiated in hypothalamus
◦ Sympathetic nervous system
◦ Norepinephrine release at the site of brown fat
◦ Non- shivering thermogenesis is initiated and brown
fat is burned for energy to keep the body temperature
stable
This is the infant’s initial response
14. Brown fat is an
energy source for
infants
It can be found:
◦ Near Kidneys and
adrenals
◦ Neck, mediastinum,
scapular, and the
axilla areas.
Can not be replaced
once used
15. In full term infants
◦ 4 % -10% of adipose deposits
In preterm infants
◦ Not be found until 26-30 weeks gestation
◦ Then only in small amounts
Disappears 3-6 months after birth
◦ In cold stressed infants
Disappears sooner
Hypoxia causes impairment of brown fat
metabolism
16.
17. A large surface area-to-body mass ratio
Decreased subcutaneous fat
Greater body water content
Immature skin leading to increased evaporative
water and heat losses
Poorly developed metabolic mechanism for
responding to thermal stress (e.g. no shivering)
18. Premature
SGA
Neuro problems
Endocrine
Cardiac / respiratory problems
Large open areas in the skin
Sedated Infants
Drug exposure
19. Anesthesia-induced inhibition of central
thermoregulation
Internal redistribution of heat from the central
to the peripheral compartment
Reduction in metabolic heat production
Increased exposure to the environment
◦ up to 90% of heat loss occurs via skin mainly by radiation and convection
20. Patterns of body temperature
after general anesthesia
1.Internal redistribution of heat
2.Thermal imbalance
3.Thermal steady state (plateau or
rewarming)
21.
22. Definition:
It is a condition characterized by lowering of
body temperature than 36.5°C.
Could be classified based on:
◦ Causes:
Primary and secondary
◦ Severity:
Mild( 35-36.4ºc)
Moderate(32-34.9ºc)
Severe (<32ºc)
23. Hypoxemia
Hypoglycemia
Respiratory & metabolic acidosis
Inhibition of surfactant production
pulmonary blood flow
pulmonary vascular resistance compromises the
delivery of oxygen at the cell level
risk of developing PPHN
24. Mild hypothermia
◦ Skin-to-skin contact
In a warm room
At least 25°C
◦ Covering of head with
cap
◦ Cover mother and
newborn with warm
blankets
Moderate hypothermia
◦ Under a radiant heater
◦ In a warmed incubator
◦ In a heated water-filled
mattress
◦ skin-to-skin contact with the
mother
Severe
◦ Warm incubator
◦ Skin to skin contact in warm room
25. Warm chain
1)Warm delivery room
2)Immediate drying
3)Skin-to-skin contact
4)Breast-feeding
5)Bathing and weighing postponed
6)Appropriate clothing/bedding
7)Mother and baby together
8)Warm transportation
9)Warm resuscitation
10)Training and awareness raising
26. RADIANT HEAT LOSS
◦ Avoiding placement of incubators,
warming tables and bassinets near cold
windows, walls, air conditioners, etc..
◦ Placing a knit hat on the infant’s head
◦ Wrapping tiny babies in saran or “bubble”
wrap
◦ environmental temperature
27. EVAPORATIVE HEAT LOSS
◦Keeping the neonate and his/her
environment dry
◦Drying the baby immediately after
delivery
◦Placing preterm or SGA infant in
occlusive wrap/bag at delivery
◦Delay bath until temperature is
stable
28. CONDUCTIVE HEAT LOSS
◦ Placing a warm diaper or blanket
between the neonate and cold surfaces
◦ Placing infant on pre-warmed table at
time of delivery
◦ Warming all objects that come in
contact with the neonate
◦ Admitting infant to a pre-warmed
room
◦ Skin to skin contact
29. CONVECTIVE HEAT LOSS
◦ Providing warm ambient air temperature
Placing infants less than 1500 grams in
incubators
Keeping portholes of the incubator closed
Warming all inspired oxygen
On open warmers keeping sides up and
covering infant if possible
Using Infant Servo Temperature Control
30. Preoperative warming
◦ To keep a patient comfortably warm
◦ To prevent phase I hypothermia
◦ Techniques
Active- with forced air warming
Passive- with passive insulation
Warm blanket
Socks
Warm circulating water mattress
Head covering
◦ Duration ???
30’ to 1hr
31. Operating room warming
◦ Reduces the temp. gradient
◦ Ideally
For preterm …minimum 29ºc
Term…..27ºc
Adult……21ºc
◦ Relative humidity
40-60%
Using warm fluids
◦ Both IV and irrigations
Humidified and warm inspired gases
◦ With HME device.
32. Appropriately covered during any transport
◦ Older children and adults
A warm blanket may be sufficient
◦ Neonates and premature babies
Transport in a prewarmed incubator, or
Chemical heating pads
33. Most commonly used to warm patients in post
anesthesia recovery room
◦Forced air blankets
◦Radiant heaters
34.
35. Increased intraoperative blood loss and
transfusion
Adverse cardiac events
Prolonged stay in RR and hospital
Delayed surgical wound healing and high rate of
infection
Cold induced coagulation dysfunction
Prolonged drug metabolism
36.
37. CORAN PEDIATRICS SURGERY 7TH EDITION
Atlas procedures in neonatology
Pediatric Anesthesia : Bruno Bissonnette
Thermal protection of the newborn: a practical
guide. WHO/RHT /MSM/97
Uptodate
Maintaining a neutral thermal environment is one of the key physiologic challenges that a newborn must face after delivery
Hypothermia is one of the commonest cause of morbidity and mortality of newborns
In early 1900s
Realized warm environment was essential in the care of low birth weight and preterm newborns because they couldn’t maintain their own body temprature
Last decades
Improved care of newborns in developed world because of awareness of importance of creating warm enviroment
Still common problem in developing countries, this situatation results more from lack of knowledge rather than lack equipements
because in most parts of developing country, there is little understanding of the thermal needs of newborn babies and of the extent and significance of neonatal hypothermia
Thermal care is central to reducing morbidity and mortality in newborns.
The average “normal” axillary temperature is considered to be 37°C (Leduc & Woods, 2013).
The Canadian Paediatric Society recommends taking temperature via the axillary route to screen low risk newborns from birth to 2 years (Leduc & Woods, 2013). There is a lack of evidence on what constitutes the “normal” temperature range for a newborn. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) (1997) and the World Health Organization (WHO) (1997; 2003) define normal axillary temperatures to be between 36.5°C and 37.5°C. The Acute Care of at-Risk Newborns Neonatal Society (ACoRN) define normal axillary temperature to be between
36.3°C-37.2°C (ACoRN, 2012).
Hypothermia
Hypothermia occurs when the newborn’s axillary temperature drops below 36.3°C (ACoRN,
2012) or below 36.5°C (AAP/ACOG, 1997; WHO, 1997). The following characteristics put
newborns at a greater risk of heat loss:
· A large surface area-to-body mass ratio
· Decreased subcutaneous fat
· Greater body water content
· Immature skin leading to increased evaporative water and heat losses
· Poorly developed metabolic mechanism for responding to thermal stress (e.g. no
shivering)
· Altered skin blood-flow (e.g. peripheral cyanosis)
(Aylott, 2006; Blackburn, 2007; Galligan, 2006; Hackman, 2001; WHO, 1997)
PHYSIOLOGY OF THERMOREGULATION
Normal body temperature is maintained constant by a balance of heat loss and heat gain with the assistance of an efficient
thermoregulatory mechanism. Extreme environmental temperature variations, however, can overcome this effective thermoregulatory
function and lead to heat- or cold-related illnesses.
Body temperature consists of core and shell temperatures. Rectal, esophageal, bladder, and oral temperatures represent core temperature, whereas axillary and skin temperatures represent shell temperature.
Core temperature determines the risk of injury to various organs in the body. Air temperature, air movement, thermal radiation, sweating, skin blood flow, and temperature of underlying tissue all influence shell temperature (1).
Thermoreceptors for the shell reside in the skin.
Core thermoreceptors exist in the cortex, hypothalamus, midbrain, medulla, spinal cord, and deep abdominal structures in addition to the skin (2,3). On sensing a temperature
change, these receptors transmit afferent impulses via the lateral spinothalamic tract to the central thermostat located in the preoptic/anterior hypothalamus, which maintains the temperature set point (4).
Thermoregulation is initiated when sensed temperature is different from the set point. The conditions associated with failed thermoregulatory mechanisms that lead to hyperthermia or hypothermia will be discussed in this chapter
Heat Gain
Warm-blooded animals have the capacity to raise their body temperature above their environmental temperature, which occurs when
endogenous or exogenous heat gain exceeds heat loss. Heat is generated in the human body from basal metabolism, physical activity,
food consumption, metabolic activity, emotional change, hormonal effects, and certain medications that typically raise body metabolism.
The body may also acquire heat passively when the environmental temperature exceeds body temperature.
Heat Loss
Heat is lost from the body via conduction, convection, radiation, and evaporation. In most situations, humans produce more heat than
necessary and dissipate the excess heat into the environment.
Conduction is heat loss by the transfer of heat from a warmer to a cooler object when the two objects are in direct contact. The amount of
heat loss depends on the contact area and the temperature difference between the body and the other surface. Typically, only 3% of
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body heat is lost by conduction; however, conduction may be a major source of heat loss in wet clothing or immersion incidents because
of the excellent conductive properties of water.
Convection is heat loss by the movement of air or fluid that circulates around the skin. More heat is carried away from the body in windy
conditions, as the movement of air rapidly removes the insulating layer of warmer air normally around the body surface. Approximately
12%-15% of body heat is lost by convection.
Radiation is heat loss due to infrared heat emission to surrounding air. Heat loss occurs primarily from the head and noninsulated areas
of the body and usually occurs rapidly. Radiation can account for 55%-65% of heat loss.
Evaporation is heat loss by the change of water from a liquid (sweat) to a gas state via the skin or respiration. Evaporation normally
accounts for 25% of heat loss, but depends on surface area, temperature difference, and humidity. Evaporative heat loss is highest in
cold, dry, and windy conditions
Thermoneutral zone: The range of ambient temperature required for the infant (for each gestational age and weight) to keep a normal body temperature (core body temperature from 36.5°C to 37.5°C) and a minimal basal metabolic rate
Extreme environmental temperature variations, however, can overcome this effective thermoregulatory
function and lead to heat- or cold-related illnesses
Physical process of converting liquid to vapor
Accounts major cause of heat loss…50%
Heat loss occurs from energy needed to vaporize liquids from skin,lung,mucosa and serosa
Depends on
The exposed body surface area
Relative humidity of the ambient air
the speed of the wind
Radiation
Energy transmitted by waves through the medium
Heat loss to the nearby cold objects with out physical contact
Major source of heat loss in most surgical patients
Depends on
The T differences
The body exposed to the environment
The skin blood flow
Radiation: when the newborn is near cool objects, walls, tables, cabinets, without actually being in contact with them. The transfer of heat between solid surfaces that
are not touching. Factors that affect heat change due to radiation are temperature gradient between the two surfaces, surface area of the solid surfaces and distance between solid surfaces. This is the greatest source of heat loss after birth
Most cooling of the newborn occurs immediately after birth. During the first 10 to 20
minutes, the newborn may lose enough heat for the body temperature to fall by 2-4°C if
appropriate measures are not taken. Continued heat loss will occur in the following hours if
proper care is not provided. The temperature of the environment during delivery and the postnatal period has a significant effect on the risk to the newborn of developing
hypothermia.
Conduction
Heat transfer from warm to cool objects with direct contact
Accounts 5%
Depends on
Area of body exposed
Relative difference in temperature
Thermal conductivity…low in air, is approximately 25 times more rapid in water
Conduction: when the newborn is placed naked on a cooler surface, such as table, scale, cold bed. The transfer of heat between two solid objects that are touching, is
influenced by the size of the surface area in contact and the temperature gradient
between surfaces
Convection
Occurs when air flow
carries heat to or
away from the body
Special type of conduction heat loss through moving gases
Accounts 15%
Second most common heat loss in anesthetized pt
Depends on
The temperature difference
The speed of air
Proportional to the square root of air speed
· Convection: when the newborn is exposed to cool surrounding air or to a draft from open doors, windows or fans, the transfer of heat from the newborn to air or liquidis affected by the newborn’s large surface area, air flow (drafts, ventilation systems, etc), and temperature gradient.
Heat Production
4.1 During pregnancy maternal mechanisms maintain the intrauterine temperature. After birth the newborn must adapt to their environment by the metabolic production of heat.
4.2 Primary source of heat in the newborn is non-shivering thermogenesis which involves the utilisation of brown adipose tissue.
Metabolic processes
The brain, heart, and liver produce the most metabolic energy by oxidative metabolism of glucose, fat and protein. The amount of heat produced varies with activity, state, health status, environmental temperature.
Voluntary muscle activity
· Increased muscle activity during restlessness and cryinggenerate heat.
· Conservation of heat by assuming a flexed position to decrease exposed surface area
Voluntary Muscle Activity
The mechanical efficiency of muscle contractions—the ratio between power output and the sum of the caloric equivalent of oxygen consumption and power output—can initially reach up to 50% for short exercises (seconds), but quickly decreases to levels in the range of 25 to 35% for sustained, steady-state
exercise (e.g., cycling).175,176 This forms the basis of heat generation by voluntary muscle activity, because most of the difference
between energy input and mechanical energy output is converted
into heat. However, during anesthesia, this form of heat
generation is, similar to thermoregulatory behavioral changes,
either absent or only minimal and does not significantly con -
tribute to thermoregulation
Peripheral vasoconstriction
· In response to cooling, peripheral vasoconstriction reduces blood flow to the skin and therefore decreases loss of heat
from skin surfaces.
Nonshivering thermogenesis
· Heat is produced by metabolism of brown fat.
· Thermal receptors transmit impulses to the hypothalamus, which stimulate the sympathetic nervous system and causes norepinephrine release in brown fat (found around the scapulae, kidneys, adrenal glands, head, neck, heart, great vessels, and axillary regions).
· Norepinephrine in brown fat activates lipase, which results in lypolysis and fatty acid oxidation.
· This chemical process generates heat by releasing the energy produced instead of storing it as Adenosine-5-Triphosphate
(ATP).
Neonates and small infants are not able to shiver because of combination of
=====immaturity of musculoskeletal system, and limited muscle mass or bulk
=====there are reports of shivering….but the effectiveness on temperature regulation is negligible
When the air temperature around the baby is cool
thermoreceptors in the skin are stimulated.
Non- shivering thermogenesis is initiated and brown fat is burned for energy to keep the body temperature stable.
This is the infant’s initial response.
What is next
Conversion of brown fat uses oxygen and glucose
Therefore, the cold stressed infant will become hypoxic and hypoglycemic
Blood gas and glucose levels are affected
Growth is affected as calories are used to stay warm rather than grow
Important factors :
Integrated CNS pathways
Adequate glucose
Oxygen
Adequate Brown
In full term infants brown fat is 4 % -10% of adipose deposits.
In preterm infants, brown fat will not be found until 26-30 weeks gestation, and then only in small amounts
Brown fat generally disappears 3-6 months after birth, except in cold stressed infants (where it will disappear sooner, Clinically significant nonshivering thermogenesis
is possible within minutes after birth and may persist up to the age of 2 years.
Hypoxia causes impairment of brown fat metabolism
The following characteristics put
newborns at a greater risk of heat loss:
· A large surface area-to-body mass ratio :Infants have more skin surface per pound of body weight than older
children or adults -More skin means more radiant heat and more insensible water loss
· Decreased subcutaneous fat
· Greater body water content
· Immature skin leading to increased evaporative water and heat losses
· Poorly developed metabolic mechanism for responding to thermal stress (e.g. no shivering): Shivering, which is the main way in which older children and adults generate heat, is
impossible or not effective in infants. Neonates and young infants generate heat by burning brown fat
· Altered skin blood-flow (e.g. peripheral cyanosis)
Newborn infants are at risk for heat loss and hypothermia for several reasons.
Relative to body weight, the body surface area of a newborn infant is approximately 3 times that of an adult.
Generation of body heat depends in large part on body weight, but heat loss depends on surface area.
In low birthweight and preterm infants, the insulating layer of subcutaneous fat is thin. The estimated rate of heat loss in a newborn is approximately 4 times that of an adult.
Under the usual delivery room conditions (20-25°C [68-77°F]), an infant’s skin temperature falls approximately 0.3°C (0.54°F)/min and deep body temperature decreases approximately 0.1°C (0.18°F)/min during the period immediately after delivery; these rates generally result in a cumulative loss of 2-3°C (3.6-5.4°F) in deep body temperature (corresponding to a heat loss of approximately 200 kcal/kg).
The heat loss occurs by 4 mechanisms: (1) convection of heat energy to the cooler
surrounding air, (2) conduction of heat to the colder materials touching
the infant, (3) heat radiation from the infant to other nearby cooler
objects, and (4) evaporation from skin and lungs.
Factors affecting heat loss
Infant
Large surface area relative to body mass
Relatively large head with highly vascular fontanelle
Skin maturation/thickness, epidermal barrier functionally mature at 32 to 34 weeks. Transepidermal water loss may be 10 to 15 times greater in preterm infants of 25 weeks' gestation (4).
Decreased stores of subcutaneous fat and brown adipose tissue in more premature infants (7)
Inability to signal discomfort or trigger heat production (shivering) (7)
Environment (3,4)
Physical contact with cold or warm objects (conduction)
Radiant heat loss or gain from proximity to hot or cold objects (radiation)
Wet or exposed body surfaces (evaporation)
Air currents in nursery or in incubator fan (convection)
Excessive or insufficient coverings or clothing
Other factors
Metabolic demands of disease: asphyxia, respiratory distress, sepsis (11)
Pharmacologic agents, e.g., vasodilating drugs, maternal analgesics, and unwarmed IV infusions, including blood products
Medical stability of infant prior to procedure
Thermogenic response matures with increase in postconception age (4)
Premature
=====less brown fat and glycogen stores decreased ability to maintain flexion, increased body surface area compared to weight
Allmost all anesthesia drugs affect thermoregulation mechanism
Eg. Narcotics…reduces vasoconstriction effect for heat conservation
musle relaxants …reduces musle tone and shivering
regional anesthesia…causes sympathetic blockage, musle relaxant, sensory blockage
Anesthesia-induced inhibition of central thermoregulation.338
2. Internal redistribution of heat from the central to the periph -
eral compartment.329
3. Linear reduction in metabolic heat production as a function of
mean and core body temperatures (4–8%/°C).339
4. Increased exposure to the environment (up to 90% of heat loss
occurs via skin mainly by radiation and convection).
Altered responses to heat loss due to anaesthesia (e.g. lack of shivering)
• Increased heat loss-environment exposure
• Cooling effect of cold anaesthetic gases and intravenous fluids
• Reduced heat production due to reduced metabolic activity
PHASE 1 / REDISTRIBUTION
This is due to vasodilatation causing redistribution of heat from core to periphery following
induction of anaesthesia. Body heat content initially remains unchanged.
PHASE 2 / LINEAR PHASE
There is a more gradual reduction in core temperature of a further 1-2oC over the next 2-3hrs. This
usually begins at the start of surgery as the patient is exposed to the cold cleaning fluids, and
exposure to the cold theatre environment. Heat loss exceeds heat production. The various modes of
heat loss are:
Phase 1/Redistribution
Phase 2/Linear
Phase 3/ Plateau
• Radiation: contributes to most of heat loss - approximately 40% and is proportional to the
environment/core temperature difference (to the power of four).
• Convection up to 30% and is due to loss of heat to air immediately surrounding the body. It is
proportional to the velocity of the air.
• Conduction: up to 5% and is due to heating surfaces in contact with the body such as theatre table
or cold fluids.
• Evaporation contributes to 8-15% and occurs from cleaning fluids, skin, respiratory, bowel and wound surfaces.
• Respiratory 8-10% enhanced by cooling effect of cold anesthetic gases.
PHASE 3 / PLATEAU
Once core temperature falls below the thermoregulatory threshold, peripheral vasoconstriction increases and acts to limit the heat loss from the core. When core heat production equals heat loss to the periphery, core temperature reaches a plateau. This may not be achieved in diabetics with autonomic neuropathy and impaired vasoconstriction and also during combined general and regional anesthesia.
Hypoxemia from increased Oxygen consumption
Hypoglycemia from increased glucose metabolism
Respiratory & metabolic acidosis secondary to anaerobic metabolism
Inhibition of surfactant production related to increased acidosis
pulmonary blood flow related to pulmonary vasoconstriction in response to body temperature
pulmonary vascular resistance compromises the delivery of oxygen at the cell level
risk of developing PPHN in the near term, term or post term infant
If no equipment is available or if the newborn is clinically stable, skin-to-skin contact with the mother can be used in a warm room (at least 25°C)
Severe hypothermia (body temperature below 32°C)
· Using a warm incubator (should be set at 1 to 1.5°C
higher than the body temperature) and should be
adjusted as the newborn’s temperature increases
· If no equipment is available, skin-to-skin contact or a warm room or cot can be used
PRE-OPERATIVE
Keep the patient comfortably warm (36.5-37.5 0C) by providing sheets/warm clothes and by maintaining higher ambient temperature. If temperature is below 36oC commence forced air warming unless immediate surgery is imperative.
A forced air warming system is a medical electrical devices used to help keep pts warm during anesthesia and surgery .it comprises a reusable controller and disposable single use blankets
Controller-----components are electronic motor and fan, electronic heating element, thermostats, air filter, hose
===the fans draws in air through the filter , and heating elements heat it to a selected temperature controlled by thermostat
===heat air travels through the hose to the blanket which connects to the hose nozzle
Blanket===double layer and inflates in operaton
====the patient contact surface is permeable to air and the warm air exits the blanket and moves over the patients skin and transfer heat to the patients by convection
INTRA-OPERATIVE MEASURES
Maintain ambient temperature above 210C. Cover the patient adequately with either sheets or cotton roll or any other passive insulating material. This traps air under the insulation material and may prevent heat loss by up to 30%.
Active warming using forced air warmers such as the “Bair hugger” illustrated below are devices that blow hot air into a blanket on top of the patient. It is more efficient than passive warming and prevents heat loss both by convection and radiation. These warmers must be used with the correct blankets to prevent thermal injury.
Figure 2. Forced air warming blanket Figure 3. Intravenous fluid warmer
Use warmed irrigation fluids. Connect a blood and fluid warmer if large amounts of fluid and blood product use are anticipated. Warm and humidify Inspired gases may be warmed by using a heat and moisture exchange device.
POST OPERATIVE:
Continue to monitor temperature and use appropriate measures to prevent further heat loss and keep the patient comfortably warm. If the patient’s temperature is less than 360C then commence forced air warming until thermally comfortable.
The main mechanism of heat loss during sugery are radiation and convection upto 90%
So they depend on the temperature differences.
Warming of the OR reduces the difference and heat loss
The ideal ambient temperature should be
Term…27
preterm…29
adult…21
But these temperature range makes uncomfortable for the staff members to have discomfort….practically better to be 20-24
There is a rule of thumb…increasing of OR temperature by 1ºc reduces heat loss by 10%
convection heat loss…. Cover the patient with passive insulation
evaporation heat loss…..from respiratory tract, surgical field preparation, skin incision, open wounds, bowels….so,, relative OR humidity should be kept in the range of 40-60%
HME….heat and moisture exchange device
PATIENT TRANSPORT: Although we have focused on the intra - operative care of patients, measures to prevent hypothermia are equally important during patient transport. Patients should be appropriately covered during any transport. For older children and adults, a warm blanket may be sufficient; however, neonates and particularly premature babies should, whenever possible, be transported in a prewarmed incubator. If an incubator is not available, chemical heating pads can be used to maintain normothermia or even rewarm a small patient. Even a short inhospital transport may be all it takes to ruin all of the successful intraoperative efforts to maintain normothermia.
Due to continued peripheral vasoconstriction, they have low efficiency and take long time to warm patient. Intraoperative warming is therefore ideal.
Active warming is better compared to passive warming alone in the postoperative phase also.
Active warming helps regain temperature an hour faster.
Evidence suggests that active warming with convection is slightly superior to conductive and radiant warming in the postoperative period too.
Pulmonary artery catheter monitoring
====is the gold standard for assessing centeral body temperature
=====providing the reference tempraue against which all other other sites are compared
=====limited to use,,because of invasive ness,,,except criticlal ill child
Distal esophagus
=====in patient with ETT , MORE RELIABle than rectal, more practical than tympanic
Tympanic
……..most ideal temp monitoring site to determine cor temp
======disadv….difficult obtaining apprpraite size thermistors
===========risk of tympanic perforation
Nasopharynx
=====accurately reflect the core the temperature if the probe is positioned in correct position.
----------tip should be the posterior nasopharynx close to the soft pplatee
========d/a…air leak from the ETT falsly low t, risk of bleeding