How to Manage Hypothermia for the Liver Transplant Patient (Full Length)

How to Manage Hypothermia for the Liver Transplant Patient (Full Length)


Howdy I’m Scott Lindberg. I’m the director
of liver transplant anesthesia at Houston Methodist Hospital Houston Texas we’ve
been using the HotDog warming system now for about a year and a half We’ve gotten to where we are today because our our
prior solutions for patient warming proved inadequate on pretty much routinely Prior to using the HotDog we utilized the bair hugger forced-air warming. We used multiple different solutions under body lower body and upper body and
in combination and sometimes as many as three machines on one patient, but we failed to consistently achieve adequate warming even in the best case scenario we when we did all the right things we ended up with suboptimal body temperatures inter-op and at time of reperfusion and additionally by the time we got to the
ICU we still hadn’t recovered out regardless of using up to three machines
to warm in our population we had a fair degree
of restriction on the body surface area that we were allowed to warm.
our program consistently utilizes intravenous bypass with cut downs in the femoral
and the left subclavian so our body surface area available to warm using forced-air was restricted we tried utilizing the under bodies and
that proved to be ineffective as well since
moving to The HotDog system we’ve achieved
consistent and excellent results often having to
turn the heaters off towards the end of the case because patients became too warm.
something I never achieved even in the best cases with forced-air warming Well in liver transplants it’s very
difficult to assign outcomes to any one individual thing. We
have noticed with improved warming we have, you
can definitely associate that with decreased rate of malignant arrhythmias
during reperfusion or prior to reperfusion we’ve had several malignant arrhythmias that were precipitated by hypothermia in patiences with
with low magnesium levels and our the liver transplantation liver, liver
failure patients often have prolonged QTCs at baseline
which puts them at risk of torsades and in patients who have hypothermia that risk
is increased and we have seen that in patients who are hypothermic and we have not seen that
with patients who maintain normothermia infectious infectious risks are you know
a very complicated question I think it’s imperative that we maintain warming because it
has been shown to decrease wound site infections with by avoiding hypothermia but teasing out I have not done I have not done the assessment to tease out that
difference whether prior to pre versus post this new process it decreased
infection risk that’s always our number one concern and looking at post transplant mortality
infecti- infection risks are routinely the number one cause of mortality and in
transplant recipients that was a huge driver in moving towards moving towards a HotDog as our warming
solution it’s still imperative that you pay attention to details and pre-warming it’s imperative in
this in any population and then attention to detail after
coming into the room and avoiding long periods of time when there’s no active
warming is essential while placing the lines it’s essential that
we make sure that we’re warming in that interval prep prior to the surggeons being available in
the room and once we prep we make sure that
initiate warming from the get-go this is available to us now with the with the
introduction of HotDog ibecause prior to that once we started prepping we had to turn
the forced-air warmers off. With forced-air warming we had a break in our ability to
warm patients from the time we started prepping until after the drapes were up for fear
of contamination of the field with the forced-air warning. with theHotDog we were able to actually place the place the warming devices in the position
we wanted for the entire case and activate them without a break
at all and maintain warming through the period of time
prepping draping and straight through to the end of the
case with no break We found that there are several tricks to
improving the efficiency of the warming device using hot dog
as any warming device and the the important factors are the body surface
area that’s covered by the device with temperature in the device and the
coefficient and heat transfer from the device to the patient a lot of those
things are not modifiable at the end-user stage but we have… the big key
points are to collaborate with your surgical
colleagues to ensure that you are covering the greatest degree of body
service area that you can. Some small techniques that we found useful was make
sure that the blankets are in good opposition to the patient the heat
transfer afforded by, by contact is greater than that through… through the, through convective transfer through the air to make sure that you have good
opposition of the blankets to the patient that the, the underbody is well
positioned to be you know not extending past the shoulders here shoulders
down this is actually the setup that we use
of utilizing my operating room. we have the the underbody warming mattress the
lower, the lower body warming blanket and the multiple position warming blanket for the arms In a liver transplant
at my institution we actually have a more restricted access to the patient
requiring access to the interior chest also we position more like this
this blanket cheated down a little bit here but you know this is a similar situation we would have in our operating room the beauty of these multiple position
blankets is they produce a great deal of functionality and if
you don’t have the arm axis this can be actually utilized on the head. it can be
utilized on the arms the more body surface area you can cover the more
effective it’s going to be so if you can bring these up by up onto the chest you
get better get better coverage on the chest you’re gonna get a better perfect but we’ve achieved good results just the way I showed you a minute ago We utilize Megadyne pads for grounding
solutions. We actually place the HotDog on top of the Megadyne pad, the Megadyne pad is then restricted to just the mid thigh down, and actually we have never had an issue with connections to the Megadyne pad with the HotDog on top of it Routinely we monitor core temperature through bladder temp and blood temp, occasionally if we’re doing a combined liver kidney transplant we
don’t have bladder temps and so in cases we’ll monitor blood temp and nasopharyngeal temps In my institution it’s, in my experience the
liver transplant case has been the most difficult case to
achieve consistent and reliable normothermia in. And to this day the only
product that has reliably produced normothermic conditions pre-incision and PACU and on discharge to the ICU has been HotDog warming blankets.

Leave a Reply

Your email address will not be published. Required fields are marked *