Aspects of Successful Surgery Essay

Introduction

The main aim of surgery is to improve health outcomes of patients. Patient safety is an important aspect during surgery (Steelman & Graling 2013). Over the years, the issue of maintaining and/or regulating patients’ perioperative temperatures has been eliciting a significant amount of interest among caregivers across the world (Hooper et al 2010).

It is worth noting that the body temperature of any healthy individual is maintained at a certain value, the average figure being 37 degrees Celsius (Roberson, Dieckmann, Rodriguez & Austin 2013). Clinicians measure body temperatures so that they can conclude about conditions of patients. For example, some diseases and health conditions may lead to immunological actions that result in a temperature rise (hyperthermia).

Hyperthermia is not good for biological activities in the human body because catalysts that facilitate all life processes function best at 37 degrees Celsius. Likewise, hypothermia is not ideal for biological activities due to the same reason of catalysts acting at the normal body temperature (Moola & Lockwood 2011). Thus, clinicians are guided by body temperature of a patient to initiate a certain regimen of medications.

Clinical thermometers are excellent tools that are applied to measure human temperature. Several studies have shown that patients undergoing anaesthesia of more than thirty minutes should have their temperatures monitored (Roberson et al 2013). The same has been recommended for individuals undergoing major surgery under neuraxial anaesthesia. Although internal body temperature is maintained within a very narrow range, it has been shown that general anaesthesia results in significant dose-dependent reductions in the core temperature.

The reductions trigger cold defence mechanisms, including vasoconstriction and shivering. In fact, it has been established that the anaesthetic negative impact on thermoregulation that culminates in altered distribution of body heat is the key origin of hypothermia in a significant number of patients across the globe.

However, it is important to note that neuraxial anaesthesia has less impact on thermoregulation in comparison with general anaesthesia. Although epidural analgesia is correlated with hyperthermia, the cause of the elevated temperatures of the body is not yet known (Moola & Lockwood 2011; Zurita et al 2012).

Generally, surgery is exemplified by the following: exposure of the core body to a cold surrounding, administration of fluids that are not warmed via the veins and escape of water vapour from within surgical sites (Andrzejowski, Turnbull, Nandakumar, Gowthaman & Eapen 2010). That notwithstanding, research has shown that these factors alone cannot lead to hypothermia.

Mechanisms that are involved in thermoregulation would be expected to maintain core body temperature in cases of surgery, which is characterised by environmental stress.

In patients who are not warmed before surgery, it is common to observe hypothermia, which is mainly caused by the failure of thermoregulatory mechanisms to maintain body temperature within the normal range. A thorough understanding the impacts of anaesthetics on thermoregulatory defences is important in evaluating various aspects of perioperative thermal disturbances (Hooper et al 2010). This is due to the fact that thermoregulatory failure has been cited as the main cause of hypothermia in surgical patients.

While discussing various aspects of perioperative and postoperative temperature, it would be critical to observe that human body temperature is not uniformly distributed to all body regions. In fact, the core body, such as deep thorax and abdomen, is about 2 to 4 degrees Celsius cooler than the legs (Hooper et al 2010).

Likewise, the skin is exemplified by lower temperatures than those of the core body. In addition, the skin temperature varies markedly based on environmental exposure. However, core body heat is tightly regulated and is determined by the temperature of peripheral tissues. While core temperature is not the ultimate body heat characterising element, it is the best indicator that could be used to measure thermal status in patients (Zurita et al 2012).

With regard to patients undergoing surgery, it is important to underscore that core temperature monitoring is important. Monitoring is essential because it helps to analyse intraoperative hypothermia, prevent elevated temperature and to detect malignant hyperthermia (Forbes et al 2009). Some of the sites that are essential for monitoring core heat of the body include tympanic membrane, pulmonary artery and nasopharynx, among others. However, these sites cannot be clinically accessed all the time. Thus, clinicians utilise sites that have been shown through research to be “near core”.

They include the mouth, bladder and skin surface. Although each of the sites has its own demerits, it can be used clinically based on the prevailing clinical circumstances. Research has not yet yielded a certain level of accuracy with regard to human body temperature. However, many studies have shown that temperature readings from various sites should not vary by more than 0.5 degrees Celsius. As a result, this smallest temperature variation has been shown to result in hypothermia-induced complications (Schwulst & Mazuski 2012).

In this context, it would be critical to note that the average core and skin-surface readings of temperature could be important in determining the thermoregulatory impacts of the various drugs used in patients undergoing surgery. In addition, the readings can be applied in the estimation of mean-body temperature.

During most anaesthesia, it is important to appropriately monitor core temperature to achieve two goals. The first goal would be to detect malignant hyperthermia while the second goal would be to measure hyperthermia and hypothermia. With regard to hyperthermia that is not localised, it can be detected by tachycardia and elevated end-tidal PCO₂ that does not correlate with minute ventilation (Hagan 2011). Although many studies have focused on malignant elevated temperatures, intraoperative malignant hyperthermia occurs in a significant number of patients across the world.

The condition could be caused by infectious fever, mismatched blood transfusions and warming (Contrada 2012). It would be important to dedicate a lot of diagnostic attention to perioperative hyperthermia due to the fact that it is exemplified by serious aetiologies (Adriani & Moriber 2013).

Perioperative thermal disturbance that results in hypothermia has been shown to have the most negative impacts on surgical patients. In fact, many studies have demonstrated that even moderate cases of hypothermia could lead to various adverse outcomes in patient populations (Hooper et al 2010).

Complications that are caused by hypothermia could include morbid myocardial conditions that interfere with sympathetic nervous system, patient shivering and discomfort, prolonged wound healing time, and prolonged hospitalisation (Schwulst & Mazuski 2012). About thirty minutes following administration of anaesthesia, patients are characterised by below normal temperatures, which are caused by ineffective mechanisms of redistribution of heat in the core and peripheral body segments (Schwulst & Mazuski 2012).

This has been shown to result in reduction of core heat by about 0.5 to 1.5 degrees Celsius. Although such changes in temperature have been noted in many patients, they have been shown to vary among individuals and they are very difficult to interpret. Thus, measurements are not required in most cases. In this context, it would be essential to acknowledge the importance of monitoring body temperature of patients who are exposed to general anaesthesia for more than thirty minutes.

In addition, it should be monitored in persons who undergo surgery that takes more than one hour. Studies show that health care professionals have adopted the practice of monitoring temperature in patients undergoing major operations, which are characterised by increased chances of hypothermia (Lynch, Dixon & Leary 2010).

Thus, it appears that caregivers should assess the chances of a patient encountering complications, which could be prevented by maintaining perioperative temperature. The assessment would be essential in improving health care outcomes among surgical patients.

Due to the fact that neuraxial anaesthesia negatively impacts behavioural thermoregulatory mechanisms, which are important in cold detection, patients and caregivers are not aware of hypothermia development during the anaesthesia. Thus, it would be critical to note that health care professionals measure core temperature in patients undergoing regional anaesthesia. However, neuraxial anaesthesia has not been associated with temperature monitoring.

Biological events that process thermoregulation information in the body occur in an orderly fashion. In fact, they have been shown to follow these processes: “afferent thermal sensing, central regulation and efferent responses” (Steelman 2011, p. 96). Most components of the sensing apparatus have been shown to pass through the spinal cord, but the spinal tract is not involved in communicating thermal information.

With regard to temperature regulation, studies have shown that structures of the central nervous system (CNS) compare thermal inputs from each site of the body with specific thermoregulatory responses. Thresholds have been established that must be surpassed in order for a response to occur (Lynch et al 2010). Interestingly, it is worth noting that behavioural regulation is the most essential effector of thermal control of the human body.

For example, in cases where temperatures are either extremely cold or hot, individuals change their behaviours so that they could tolerate such temperatures. However, surgical patients are disadvantaged with regard to the use of behavioural thermoregulation mechanisms. As a result, they utilise other responses that are controlled by the autonomic nervous system. They include “vasoconstriction, shivering and sweating” (Steelman 2011, p. 96).

Among these mechanisms, research has shown that vasoconstriction is the best approach that is adopted by patients. In fact, it is responsible for a significant number of perioperative thermal perturbations (Lynch et al 2010).

From an immunological standpoint, fever is interceded by pyrogens that circulate endogenously. Hyperthermia can “be caused by many causes, most of which are serious and they may include infection, mismatched blood transfusion, allergic reactions, and malignant hyperthermia” (Liau et al 2010, p. 155). Thus, it is imperative for caregivers to give adequate attention to perioperative hyperthermia, which would be detected through early diagnostic tests and intervened via the adoption of effective clinical strategies.

Chemical constituents of compounds that are used in anaesthesia should be considered because they could facilitate the development of postoperative complications. Notably, many anaesthetics and opioids have less impact on sweating. However, they have profound impacts with regard to shivering thresholds and constriction of blood vessels. General anaesthetics do not have much influence on gaining intensity of heat control responses in the body.

Thus, it can be noted that thermoregulatory inefficiencies cause a considerable number of perioperative thermal disturbances. Studies focusing on the dependability of thermoregulatory mechanisms based on the ages of patients indicate that “they are impaired in the elderly, but they are maintained in infants and children” (Steelman 2011, p. 96).

CNS thermoregulation control has been shown to be partially disrupted by neuraxial anaesthesia, which results in increased shivering of patients undergoing anaesthesia. It is notable that patients undergoing neuraxial anaesthesia are not exemplified by an effective autonomic nervous system. As a result, they do not detect that they have below normal body temperatures. This supports the assertion that patients undergoing major surgery should have their body temperatures monitored. In addition, they should be warmed to avoid hypothermia conditions in prolonged anaesthesia.

Surgery and anaesthesia is associated with wound infections, which could lead to prolonged hospitalisation (Long et al 2013). In fact, it has been shown that wounds acquired through surgical methods could increase the period of hospitalisation by about 5 to 20 days (Liau et al 2010). Extended hospitalisation has also been shown to result in increased medical costs (O’Brien, Kumar & Metersky 2013). Wound infections are common in hospital wards.

For example, studies show that three to twenty-two percent of patients who undergo colorectal surgery have the chances of developing would infections (Nicholson 2013; Sammour, Kahokehr, Hayes, Hulme-Moir & Hill 2010). However, the chances are impacted by other factors such as the period of surgery and medical problems of patients. Most of postoperative complications are caused by mild perioperative hypothermia (Liau et al 2010; Long et al 2013). This form is hypothermia is caused when “the body temperature decreases by two degrees Celsius below the normal temperature” (Steelman 2011, p. 96).

It is induced by impairment of thermoregulation, cold exposures and disrupted distribution of heat in the body. In cases where impaired immunity and vasoconstriction occur, they increase the chances of an individual to develop perioperative wounds. It is also important to note that sufficient intraoperative hypothermia is crucial in triggering vasoconstriction that is initiated by thermoregulatory mechanisms. Research has indicated that postoperative vasoconstriction is common patients who are characterised by hypothermia.

Vasoconstriction reduce the extend to which tissues function by decreasing the amount of oxygenated blood that reaches them. The reduced partial pressure of oxygen increases the chances of contracting an infection due to reduced ability of the immune system to fight diseases. Thus, it is evident that mild hypothermia could be a catalyst for many complications that could result from surgery (Fred, Ford, Wagner & VanBrackle 2012).

Health care professionals focus on preventing unintentional postoperative hypothermia (Forbes et al 2009). In fact, “prevention has become an important approach in perioperative management of patients undergoing general anaesthesia” (Forbes et al 2009, p. 500). Caregivers focus on continuous monitoring of core temperature readings on patients and adjusting temperatures in theatres to more than twenty-one degrees Celsius.

In addition, fluids that are offered to patients intravenously are warmed to 38 to 40 degrees Celsius (Kim, Kim, Lee, Choi, Shin & Jeong 2014). In case core temperature is below 36 degrees Celsius, then a patient is given forced air that is exemplified by warm air (Andrzejowski et al 2010; Egan et al 2011). All these approaches are aimed at preventing postoperative complications, some of which could be fatal (Forbes et al 2009).

However, it is important to note that, prior to surgery, cutaneous warming does not lead to significant changes in core temperature (Chakladar, Dixon, Crook & Harper 2014; Jardeleza, Fleig, Davis & Spreen-Parker 2011). Instead, such warming would lead to a decrease in heat redistribution after induction of anaesthesia (Galvão, Marck, Sawada & Clark 2009).

Forced-air pre-warming is quite effective if it is applied for more than 30 minutes (Winslow & Kelly 2012). It increases the amount of heat in the peripheral tissues (Egan et al 2011; Horn, Bein, Böhm, Steinfath, Sahili & Höcker 2012; John, Ford & Harper 2014). Research has established that “patients undergoing major surgery could be prevented from encountering postoperative complications by being pre-warned for more than 60 minutes” (Adriani & Moriber 2013, p. 447). However, the periods that are suggested by various studies are not practical in daily clinical routine (Horn et al 2012; Park & Choi 2010).

This systematic review is qualitative in design and it seeks to achieve the following objectives:

• Identifying the relationships between perioperative and postoperative temperatures.
• Establishing the most common complications that are associated with the failure to maintain temperatures during surgery.
• Identifying the impacts of postoperative complications on health care facilities and on patients.
• Proposing the best approaches that would be adopted to minimise the number of complications that arise in surgical patients.

The review will adopt the following research question: Does maintaining normal temperature perioperative reduce postoperative complications in adult surgical patients? It hypothesises that control of perioperative temperature is important in preventing postoperative complications. Although the review will not involve statistical analysis, its findings will be analysed to give a reflection on whether the study question is answered.

If the assumption will not be supported by the findings, then it would be prudent to adopt the null hypothesis. In any scientific research, research questions are important because they act as a guide with regard to what should be researched. Thus, the review will revolve around gaining information that would be essential in finding answers to the adopted question.

Justification of the review

Surgery is a form of health care approach that is regarded as the last strategy in many diseases and conditions (Esnaola & Cole 2011). It is notable that the number of patients who undergo surgery every day is increasing. The use of anaesthesia has been associated with many adverse effects. The most notable impact of general anaesthesia for the purpose of this review is the disruption of body core temperature, which is important in the biological activities of all tissues.

The balance between perioperative and postoperative temperatures is of much concern in this review. It is evident that core body temperature changes when a patient is undergoing general anaesthesia or major surgery (Esnaola & Cole 2011). In these situations, thermoregulatory mechanisms may fail to control body temperature. Thus, heat is not redistributed effectively. This is a great impact on the immunity of the body. In fact, the immune system is negatively impacted and it cannot fight infections. Another adverse effect of perioperative hypothermia is postoperative wounds.

It is worth understanding that wounds can impact the pace at which a patient recovers from a surgery. However, the goal of health care is to facilitate the speed at which a patient recuperates. It is important to conduct this systematic review because it would give important information that is related to perioperative temperature and postoperative complications. For example, it would be essential to understand what other studies have recommended to be the minimum temperature of a patient who is about to undergo general anaesthesia. In addition, the study might encounter some inconsistencies in studies that have dealt with the topic.

If discrepancies are established, then it would be important to pinpoint them and recommend for the right actions with regard to studies in the future. In fact, discrepancies might lead to the identification of research gaps that would be addressed by future studies. In a dynamic health care world, the review would be important because it would contribute to the growing amount of information about the topic. Mostly importantly, it is essential to acknowledge that systematic reviews are aimed at consolidating huge information from several studies.

The data are analysed to result in evidence-based information that is applied by caregivers to improve health outcomes. Thus, it would be expected that the study would result in improved outcomes of general anaesthesia and surgery. Improved outcomes would imply that patients would less time in health care facilities and they would also spend less money on health care. Finally, the review would be critical in offering recommendations to health care providers and patients who would have interests in the topic being explored.

Protocol

The systematic review would aim at analysing eight (8) articles published in peer-reviewed journals. Due to huge amounts of information that are experienced when conducting systematic reviews, it is recommended that they should use particular plans that act as important platforms.

The review will utilise a peer-reviewed approach, which will involve searching of databases that would contain information with regard to the impacts of maintaining perioperative temperature and preventing postoperative complications. Strategies that would be applied to search electronic databases will be designed and verified by a specialist exemplified by a wealth of experience about medical information. However, he or she will be in consultation with the team spearheading the review.

Web search engines are types of websites that enable computer users to locate user-defined information on the internet. Commonly used search engines that will be used include Google, Bing and MyWebSearch. However, the use of other sites, such as MEDLINE and EMBASE would ensure that papers would be downloaded. In fact, the websites can be used to preview important information about journal articles. For example, it would be important to preview and ascertain the year of publication before a paper would be downloaded.

Another important website or database that would be searched for critical studies will be the site containing RCTs published on Cochrane Central. It is important to note that the database would only be accessed via OVID. The search approaches would adopt both regulated vocabulary and keywords. In order to improve electronic searches, scanning of the references included in various studies will be made. It would be important to note that searches would not be limited on the basis of country of publication.

However, papers to be reviewed would be published in English. Thus, articles published in other languages would be excluded from the study and language ineligibility would be given as the main reason for exclusion. Because the review would focus on human beings, studies involving animals would be excluded. In addition, peer-reviewed articles would only be selected for analysis if they would be published within the last 5 years. In other words, articles would be chosen if they would be published starting from 2009 to date.

In fact, any papers before 2007 cannot be considered because electronic searches exhibit that a systematic review with regard to the topic of interest was published in 2009. Previous studies would not be excluded on the basis of publication significance or reported outcomes. It is expected that online searches would yield a significant number of RCTs. Thus, the review will aim at excluding all non-randomised studies. Research has shown that RCTs are important in clinical trials and other health-related studies because they involve the adoption of study subjects that are randomly selected.

Random selection of study participants minimises the chances of a researcher choosing a sample size that is biased. Outcomes of the searches would include the following: use of pre-warming methods, hyperthermia, hypothermia, perioperative temperatures, postoperative temperatures, and postoperative complications, among others.

In order to prevent bias in the selection of articles, it would be important for two reviewers to screen identified papers independently. In fact, the screening would involve two stages. First, a broad screening would be carried out on the grounds of available titles and abstracts. Second, full-text of papers that would pass the first stage would be checked to ensure that they are eligible for the systematic review. This would be achieved by resolving any discrepancies, which would be effectively conducted by involving a third team member.

In order to achieve a high level of data accuracy, one reviewer will be used to extract data while another team member will verify their consistency and accuracy. Consultation will be adopted to solve errors with regard to data. If it would be established that some data are missing, then it would be essential to contact study authors. In addition, the authors would be contacted for important data clarification.

The following categories of data would be obtained for all studies:

1. Study features: The first author of a publication, year the study was published, origin of researchers (country), study design, duration of follow-up, initial sample size, sample size used in analysis, the number of study subjects dropped with reasons and source of funding.
2. Population features: Criteria utilised in inclusion and exclusion, demographics of patients (such as age, gender and race), the protocol used in anaesthesia, site of surgery, underlying disease or condition, type and duration of surgery, perioperative temperature readings, intraoperative temperature values, and postoperative complications.
3. Intervention characteristics: Medications given, including doses, frequencies, timings, and periods of treatments. These features will also include drug compliance and alternative interventions.
4. Comparison intervention features: Analysis of interventions and durations of treatments.
5. Outcomes: In all cases, data will be categorised as the number of surgical patients. These patients should exhibit that they encountered an event. This would be critical in ensuring that multiple events would not be recorded per patient, especially if it would be established that a single patient would have encountered many events.

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