Body temperature, cutaneous heat loss and skin blood flow during epidural anaesthesia for emergency caesarean section

Mullington, C J; Low, David A.; Strutton, Paul H.; Malhotra, Surbhi

doi:10.1111/anae.14454

Cited by 16 publications

(19 citation statements)

References 35 publications

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“…In terms of understanding the thermal influences of analgesia and anaesthesia in the parturient, we are just scratching the frozen tundra. However, as indicated by the study by Mullington et al , we are slowly, and softly snow‐shoeing our way towards progress.…”

Section: Just Right?mentioning

confidence: 91%

“…Seemingly in response, Mullington et al in a recent issue of Anaesthesia, studied 20 pregnant actively‐labouring women with effective epidural analgesia provided by levobupivacaine 0.1% with fentanyl 2 μg.ml −1 , who required a category‐2 or ‐3 caesarean section . Core (tympanic) and skin (seven sites) temperatures, as well as cutaneous heat loss (five sites) and skin blood flow (laser Doppler flowmetry probe; two sites), were measured continuously from conversion of epidural labour analgesia to caesarean anaesthesia until the end of surgery.…”

Section: Too Hot?mentioning

confidence: 99%

“…So, why do these changes happen? The investigators suggest, but did not directly measure, that the reduction in cutaneous heat loss results from ‘ blockade of active vasodilation instead of invoking thermoregulatory (vasodilator), non‐thermoregulatory (vasoconstrictor), or baroreceptor‐mediated reflex vasoconstrictive processes ’ . Such a statement deserves a more nuanced explanation, as it is likely that each of these processes are invoked to some (yet to be determined) degree.…”

Section: Too Hot?mentioning

confidence: 99%

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Too cold, too hot or just right? Temperature regulation during caesarean section

Tsen

2019

Anaesthesia

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This editorial accompanies an article by Mullington et al., Anaesthesia 2018; 73: 1500-6.Winter invokes thoughts of cozy scarves, plump down comforters and roaring wood fires marshalled against frigid temperatures, treacherously icy roads and arctic snow squalls. Thermostats in homes, office suites and operating rooms are the site of quotidian conflicts on what is considered the 'optimal temperature'. These skirmishes also occur internally, as human thermoregulation, which is controlled by the pre-optic/anterior hypothalamus, responds to information relayed from internal (core) and surface (skin) sensors. Heat conservation, generation or dissipation is controlled through a series of feedback loops, with afferent temperature stimuli from the core being significantly more influential than that from the skin; in contrast, efferent thermal responses are mostly dependent on cutaneous vasodilation and constriction to effect change. During exercise or heat exposure, skin blood flow can increase from a resting baseline of 250 ml.min À1 up to 8 l.min À1 through increases in cardiac output, redistribution of blood flow from other areas such as the splanchnic region and sweating to dissipate heat effectively [1]. In cold environments, heat conservation is reliant on cutaneous vasoconstriction, which decreases skin blood flow and heat transfer from the core to the periphery. Too cold?Despite a dynamic relationship between the hypothalamus, core and surface sensors and blood flow, the accompanying science appears 'frozen' by limitations in instrumentation or imagination. Our understanding of the thermal influences of pregnancy, labour, neuraxial analgesic and anaesthetic agents and mode of delivery remains nascent. Although a few centrally-located temperature monitoring sites (e.g. urinary bladder, oesophageal, uterine and rectal) have been studied in pregnancy, intra-arterial thermistors (particularly within the pulmonary artery, since 1972) represent the gold, but seldom used, standard [2]. Peripheral thermometers (e.g. tympanic membrane, temporal artery, axillary or oral), although more convenient for clinical use, suffer from poor diagnostic accuracy, especially in their sensitivity for detecting low-grade fever [2]. The thermal effects of pregnancy hormones and commonly used agents further confuse matters. Oestrogen, oxytocin and neuraxial morphine are associated with hypothermia, although the mechanisms for these effects remain speculative [3]. The use of neuraxial analgesia has been associated with an increase in temperature in approximately 20% of labouring women. The hyperthermia likely represents a non-infectious, systemic inflammatory process and is typically modest (simultaneously obtained mean temperature at baseline to labour maximum by site: oral, 36.6°C-37°C; tympanic, 36.8°C-37°C and intrauterine, 37.2°C-37.6°C) [4], but occasionally can progress to a clinical fever (38°C; labour epidural analgesia-associated fever (LEAF)) [5]. In contrast, most women undergoing neuraxial anaesthesia during caesarean section ...

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Section: Just Right?mentioning

confidence: 91%

Section: Too Hot?mentioning

confidence: 99%

Section: Too Hot?mentioning

confidence: 99%

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Too cold, too hot or just right? Temperature regulation during caesarean section

Tsen

2019

Anaesthesia

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“…19 Obstetric patients' cutaneous heat flux and skin blood flow were recorded as described previously for a concurrent investigation of cutaneous vasomotor tone and were previously reported separately. 14 Relevant clinical data were recorded including mass, height, BMI, American Society of Anesthesiologists physical status (ASA PS) classification and the indication for caesarean delivery.…”

Section: Measurementsmentioning

confidence: 99%

“…This study was a planned primary analysis, but data from obstetric patients were collected concurrently with an investigation of the effect of epidural top-up on cutaneous vasomotor tone. 14…”

Section: Introductionmentioning

confidence: 99%

A mechanistic study of the tremor associated with epidural anaesthesia for intrapartum caesarean delivery

Mullington

Low

Strutton

et al. 2020

International Journal of Obstetric Anesthesia

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Predictive value of neutrophil‐to‐lymphocyte ratio on admission for intrapartum maternal fever in parturients undergoing epidural analgesia: A retrospective cohort study using propensity score‐matched analysis

Li,

Deng,

Sun

et al. 2024

Intl J Gynecology & Obste

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ObjectiveTo identify the predictive value of the neutrophil‐to‐lymphocyte ratio (NLR) on admission for intrapartum maternal fever in parturients undergoing epidural analgesia (EA).MethodsIn this retrospective cohort study, propensity score matching (PSM) was applied to address covariates. Univariate and multivariate regression analyses were implemented in sequence to find out the factors influencing intrapartum fever. The receiver operating characteristics curve was applied to determine the area under the curve (AUC) of NLR for intrapartum fever.ResultsNLR and duration of EA were independent risk factors for intrapartum fever. The AUC of the combined indicator (NLR + duration of EA) was higher than that of NLR (AUC = 0.583, 95% confidence interval [CI] 0.53–0.64) and duration of EA (AUC = 0.702, 95% CI 0.66–0.75), reaching 0.715 (95% CI 0.67–0.76; p < 0.001). NLR increased predictive performance for intrapartum fever when added to the duration of EA (net reclassification index 0.076, p = 0.022; integrated discrimination improvement 0.020, p = 0.002).ConclusionNLR has limited predictive power for intrapartum fever. The combination of NLR and duration of epidural analgesia may be considered a promising predictor for intrapartum maternal fever in parturients undergoing epidural analgesia.SynopsisThe neutrophil‐to‐lymphocyte ratio is an accessible predictor for the early identification of parturients at risk of intrapartum fever.

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Body temperature, cutaneous heat loss and skin blood flow during epidural anaesthesia for emergency caesarean section

Cited by 16 publications

References 35 publications

Too cold, too hot or just right? Temperature regulation during caesarean section

Too cold, too hot or just right? Temperature regulation during caesarean section

A mechanistic study of the tremor associated with epidural anaesthesia for intrapartum caesarean delivery

Predictive value of neutrophil‐to‐lymphocyte ratio on admission for intrapartum maternal fever in parturients undergoing epidural analgesia: A retrospective cohort study using propensity score‐matched analysis

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