Heating up caesarean care – tackling perioperative hypothermia

Optimising care for women who undergo caesarean delivery in low- to middle-income settings (LMIC) presents unique challenges, one of which is the risk of perioperative hypothermia, defined as a core body temperature below 36 °C (96.8 °F). Although, caesarean delivery is a relatively short procedure, it has been estimated that inadvertent hypothermia can occur in up to 80% of women who receive spinal anaesthesia. Reasons for this include peripheral vasodilation, diminished regulatory vasoconstriction, and reduced shivering responses that promote heat redistribution during neuraxial anaesthesia, with patients who have higher sensory block levels being particularly vulnerable. The effect of perioperative hypothermia in women undergoing caesarean delivery has been incompletely studied. However, in the general surgical population it can have significant consequences including increased blood loss, wound infection, cardiovascular complications, and extended hospital stay. Maternal hypothermia also has implications for the neonate; this is particularly relevant for caesarean delivery as it has been established that for healthy term neonates, caesarean delivery causes a less favourable thermal response to birth than vaginal delivery. Maternal hypothermia may result in decreases in neonatal temperature and neonatal hypothermia, even in tropical environments. While neonatal hypothermia is rarely a direct cause of death, it does contribute to a substantial proportion of neonatal morbidity and mortality globally. The role of minimising unintentional perioperative hypothermia in improving outcomes has been recognised in guidance from the United Kingdom (UK) and United States of America.

Modelling the incidence and severity of hypothermia during spinal anaesthesia for caesarean delivery: a prospective observational study in a resource-limited setting

Hypothermia, defined as a core temperature below 36 °C or a decrease of > 1 °C from a baseline, is a common and prevalent problem in the perioperative period. Both neuraxial and general anaesthesia (GA) are known to cause hypothermia, which is associated with negative perioperative outcomes. Spinal anaesthesia (SA) is the preferred method for caesarean delivery (CD), although there remain recognised and predictable complications of this technique, such as hypotension and hypothermia. Heat loss during SA occurs predominantly through vasodilation below the block level, causing heat redistribution from core to periphery. Compounding factors include low ambient temperature and loss of normal physiological compensatory mechanisms. Perioperative strategies commonly employed to combat heat loss include forced air warming devices, increasing ambient theatre temperature and warmed intravenous fluids. However, these measures are not fully effective in preventing hypothermia in patients under SA for CD, and are not universally available in resource-limited settings.

Perceptions of the perioperative team regarding the use of the WHO Surgical Safety Checklist

The World Health Organization (WHO), urged by the World Health Assembly in a 2002 resolution to strengthen the safety of healthcare and monitoring systems, recognised surgical safety as a significant public health concern. The WHO also realised that surgical safety in developing countries is further compounded by a lack of resources, skill shortages, and underfinancing. The WHO developed the Safe Surgery Guidelines in 2007 in collaboration with experts worldwide and launched the Safe Surgery Saves Lives programme. In 2009, the WHO introduced the WHO Surgical Safety Checklist (WHO Checklist) as part of its Safe Surgery Saves Lives programme. The WHO Checklist was designed to promote safety by ensuring that preoperative, intraoperative, and postoperative safety checks are undertaken in a timely and efficient manner with open communication while fostering teamwork. Its aim was not to create a regulatory tool but rather to introduce key safety elements into the operating theatre routine without undue burden on the system or the providers.

Evaluation of hypotension following induction of general anaesthesia due to thiopentone, propofol and etomidate using perfusion index

Induction of anaesthesia is a vital part of general anaesthesia (GA), so is maintaining haemodynamic stability during induction. Intraoperative hypotension is a common complication that leads to tissue hypoperfusion and the subsequent consequences, which can raise postoperative morbidity and mortality, even following a brief period of hypotension. Hypotension, secondary to induction of anaesthesia, is more common in the latter postinduction interval, between 5 and 10 minutes after induction. As blood pressure (BP) is monitored at fixed intervals (every 3–5 minutes), short durations of intraoperative hypotension may go undiagnosed. The main risk factors for both post-induction hypotension and early intraoperative hypotension includes age, the existence of hypotension prior to induction, emergency surgery, and the type of induction drug being employed.

Does pumping iron bring gains? A review of the role of intravenous iron in perioperative blood management

Perioperative blood management (PBM) is a bundle of care practices encompassing all the key practice points for administering blood products to a patient presenting for major surgery with the risk of significant blood loss (> 500 ml in adults). PBM should be activated at the moment the decision is made for surgery and implemented until the patient has made a full recovery. PBM encompasses three main pillars in its multimodal approach, and this review relates to the first, optimising disorders causing anaemia (see Table I). Globally, routine use of preoperative intravenous (IV) iron therapy has been widely adopted to increase preoperative haemoglobin (Hb) and reduce the risk of blood transfusion. Currently, there is a paucity in robust evidence supporting this practice.

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Southern African Journal of Anaesthesia and Analgesia - Jan/Feb 2024 Vol 30 No 1