Background Mild perioperative hypothermia, which is common duringmajor surgery, may promote surgical-wound infection by triggeringthermoregulatory vasoconstriction, which decreases subcutaneousoxygen tension. Reduced levels of oxygen in tissue impair oxidativekilling by neutrophils and decrease the strength of the healingwound by reducing the deposition of collagen. Hypothermia alsodirectly impairs immune function. We tested the hypothesis thathypothermia both increases susceptibility to surgical-woundinfection and lengthens hospitalization.
Methods Two hundred patients undergoing colorectal surgery wererandomly assigned to routine intraoperative thermal care (thehypothermia group) or additional warming (the normothermia group).The patients' anesthetic care was standardized, and they wereall given cefamandole and metronidazole. In a double-blind protocol,their wounds were evaluated daily until discharge from the hospitaland in the clinic after two weeks; wounds containing culture-positivepus were considered infected. The patients' surgeons remainedunaware of the patients' group assignments.
Results The mean (±SD) final intraoperative core temperaturewas 34.7±0.6°C in the hypothermia group and 36.6±0.5°Cin the normothermia group (P<0.001). Surgical-wound infectionswere found in 18 of 96 patients assigned to hypothermia (19percent) but in only 6 of 104 patients assigned to normothermia(6 percent, P = 0.009). The sutures were removed one day laterin the patients assigned to hypothermia than in those assignedto normothermia (P = 0.002), and the duration of hospitalizationwas prolonged by 2.6 days (approximately 20 percent) in thehypothermia group (P = 0.01).
Conclusions Hypothermia itself may delay healing and predisposepatients to wound infections. Maintaining normothermia intraoperativelyis likely to decrease the incidence of infectious complicationsin patients undergoing colorectal resection and to shorten theirhospitalizations.
Wound infections are common and serious complications of anesthesiaand surgery. A wound infection can prolong hospitalization by5 to 20 days and substantially increase medical costs.1,2 Inpatients undergoing colon surgery, the risk of such an infectionranges from 3 to 22 percent, depending on such factors as thelength of surgery and underlying medical problems.3 Mild perioperativehypothermia (approximately 2°C below the normal core bodytemperature) is common in colon surgery.4 It results from anesthetic-inducedimpairment of thermoregulation,5,6 exposure to cold, and altereddistribution of body heat.7 Although it is rarely desired, intraoperativehypothermia is usual because few patients are actively warmed.8
Hypothermia may increase patients' susceptibility to perioperativewound infections by causing vasoconstriction and impaired immunity.The presence of sufficient intraoperative hypothermia triggersthermoregulatory vasoconstriction,9 and postoperative vasoconstrictionis universal in patients with hypothermia.10 Vasoconstrictiondecreases the partial pressure of oxygen in tissues, which lowersresistance to infection in animals11,12 and humans (unpublisheddata). There is decreased microbial killing, partly becausethe production of oxygen and nitroso free radicals is oxygen-dependentin the range of the partial pressures of oxygen in wounds.13,14Mild core hypothermia can also directly impair immune functions,such as the chemotaxis and phagocytosis of granulocytes, themotility of macrophages, and the production of antibody.15,16Mild hypothermia, by decreasing the availability of tissue oxygen,impairs oxidative killing by neutrophils. And mild hypothermiaduring anesthesia lowers resistance to inoculations with Escherichiacoli17 and Staphylococcus aureus18 in guinea pigs.
Vasoconstriction-induced tissue hypoxia may decrease the strengthof the healing wound independently of its ability to reduceresistance to infection. The formation of scar requires thehydroxylation of abundant proline and lysine residues to formthe cross-links between strands of collagen that give healingwounds their tensile strength.19 The hydroxylases that catalyzethis reaction are dependent on oxygen tension,20 making collagendeposition proportional to the partial pressure of arterialoxygen in animals21 and to oxygen tension in wound tissue inhumans.22
Although safe and inexpensive methods of warming are available,8perioperative hypothermia remains common.23 Accordingly, wetested the hypothesis that mild core hypothermia increases boththe incidence of surgical-wound infection and the length ofhospitalization in patients undergoing colorectal surgery.
Methods
With the approval of the institutional review board at eachparticipating institution and written informed consent fromthe patients, we studied patients 18 to 80 years of age whounderwent elective colorectal resection for cancer or inflammatorybowel disease. Patients scheduled for abdominal–peritonealpull-through procedures were included, but not those scheduledfor minor colon surgery (e.g., polypectomy or colostomy performedas the only procedure). The criteria for exclusion from thestudy were any use of corticosteroids or other immunosuppressivedrugs (including cancer chemotherapy) during the four weeksbefore surgery; a recent history of fever, infection, or both;serious malnutrition (serum albumin, less than 3.3 g per deciliter,a white-cell count below 2500 cells per milliliter, or the lossof more than 20 percent of body weight); or bowel obstruction.
The number of patients required for this trial was estimatedon the basis of a preliminary study in which 80 patients undergoingelective colon surgery were randomly assigned to hypothermia(mean [±SD] temperature, 34.4±0.4°C) or normothermia(involving warming with forced air and fluid to a mean temperatureof 37±0.3°C). The number of wound infections (asdefined by the presence of pus and a positive culture) was evaluatedby an observer unaware of the patients' temperatures and groupassignments. Nine infections occurred in the 38 patients assignedto hypothermia, but there were only four in the 42 patientsassigned to normothermia (P = 0.16). Using the observed differencein the incidence of infection, we determined that an enrollmentof 400 patients would provide a 90 percent chance of identifyinga difference with an alpha value of 0.01. We therefore plannedto study a maximum of 400 patients, with the results to be evaluatedafter 200 and 300 patients had been studied. The prospectivecriterion for ending the study early was a difference in theincidence of surgical-wound infection between the two groupswith a P value of less than 0.01. To compensate for the twoinitial analyses, a P value of 0.03 would be required when thestudy of 400 patients was completed. The combined risk of atype I error was thus less than 5 percent.24
Study Protocol
The night before surgery, each patient underwent a standardmechanical bowel preparation with an electrolyte solution. Intraluminalantibiotics were not used, but treatment with cefamandole (2g intravenously every eight hours) and metronidazole (500 mgintravenously every eight hours) was started during the inductionof anesthesia; this treatment was maintained for about fourdays postoperatively. Anesthesia was induced with thiopentalsodium (3 to 5 mg per kilogram of body weight), fentanyl (1to 3 µg per kilogram), and vecuronium bromide (0.1 mgper kilogram). The administration of isoflurane (in 60 percentnitrous oxide) was titrated to maintain the mean arterial bloodpressure within 20 percent of the preinduction values. Additionalfentanyl was administered on the completion of surgery, to improveanalgesia when the patient emerged from anesthesia.
The patients were hydrated aggressively during and after surgery,because hypovolemia decreases wound perfusion and increasesthe incidence of infection.25,26 We administered 15 ml of crystalloidper kilogram per hour throughout surgery and replaced the volumeof blood lost with either crystalloid in a 4:1 ratio or colloidin a 2:1 ratio. Fluids were administered intravenously at ratesof 3.5 ml per kilogram per hour for the first 24 postoperativehours and 2 ml per kilogram per hour for the subsequent 24 hours.Leukocyte-depleted blood was administered as the attending surgeonconsidered appropriate.
At the time of the induction of anesthesia, each patient wasrandomly assigned to one of the following two temperature-managementgroups with computer-generated codes maintained in numbered,sealed, opaque envelopes: the normothermia group, in which thepatients' core temperatures were maintained near 36.5°C,and the hypothermia group, in which the core temperature wasallowed to decrease to approximately 34.5°C. In both groups,intravenous fluids were administered through a fluid warmer,but the warmer was activated only in the patients assigned toextra warming. Similarly, a forced-air cover (Augustine Medical,Eden Prairie, Minn.) was positioned over the upper body of everypatient, but it was set to deliver air at the ambient temperaturein the hypothermia group and at 40°C in the normothermiagroup. Cardboard shields and sterile drapes were positionedin such a way that the surgeons could not discern the temperatureof the gas inflating the cover. Shields were also positionedover the switches governing the fluid heater and the forced-airwarmer so that their settings were not apparent to the operating-roompersonnel. The temperatures were not controlled postoperatively,and the patients were not informed of their group assignments.
Supplemental oxygen was administered through nasal prongs ata rate of 6 liters per minute during the first three postoperativehours and was then gradually eliminated while oxygen saturationwas maintained at more than 95 percent. To minimize the decreasein wound perfusion due to activation of the sympathetic nervoussystem, postoperative pain was treated with piritramide (anopioid), the administration of which was controlled by the patient.
The attending surgeons, who were unaware of the patients' groupassignments and core temperatures, determined when to beginfeeding them again after surgery, remove their sutures, anddischarge them from the hospital. The timing of discharge wasbased on routine surgical considerations, including the returnof bowel function, the control of any infections, and adequatehealing of the incision.
Measurements
The patients' morphometric characteristics and smoking historywere recorded. The preoperative laboratory evaluation includeda complete blood count; determinations of the prothrombin timeand partial-thromboplastin time; measurements of serum albumin,total protein, and creatinine; and liver-function tests. Therisk of infection was scored with a standardized algorithm takenfrom the Study on the Efficacy of Nosocomial Infection Control(SENIC) of the Centers for Disease Control and Prevention; inthis scoring system, one point each is assigned for the presenceof three or more diagnoses, surgery lasting two hours or more,surgery at an abdominal site, and the presence of a contaminatedor infected wound.2 The scoring system was modified slightlyfrom its original form by the use of the diagnoses made at admission,rather than discharge. The risk of infection was quantifiedfurther with the use of the National Nosocomial Infection SurveillanceSystem (NNISS), a scoring system in which the patient's riskof infection was predicted on the basis of the type of surgery,the patient's physical-status rating on a scale developed bythe American Society of Anesthesiologists, and the durationof surgery.3
Core temperatures were measured at the tympanic membrane (MallinckrodtAnesthesiology Products, St. Louis), with values recorded preoperatively,at 10-minute intervals intraoperatively, and at 20-minute intervalsfor 6 hours during recovery. Arteriovenous-shunt flow was quantifiedby subtracting the skin temperature of the fingertip from thatof the forearm, with values exceeding 0°C indicating thermoregulatoryvasoconstriction.27 End-tidal concentrations of isoflurane andcarbon dioxide were recorded at 10-minute intervals during anesthesia.Measurements of arterial blood pressure and heart rate wererecorded similarly during anesthesia and for six hours thereafter.Oxyhemoglobin saturation was measured by pulse oximetry.
Thermal comfort was evaluated at 20-minute intervals for 6 hourspostoperatively with a 100-mm visual-analogue scale on which0 mm denoted intense cold, 50 mm denoted thermal comfort, and100 mm denoted intense warmth. The degree of surgical pain wasevaluated similarly, except that 0 mm denoted no pain and 100mm the most intense pain imaginable. Shivering was assessedqualitatively, on a scale on which 0 denoted no shivering; 1,mild or intermittent shivering; 2, moderate shivering; and 3,continuous, intense shivering. All the qualitative assessmentswere made by observers unaware of the patients' group assignmentsand core temperatures.
The patients' surgical wounds were evaluated daily during hospitalizationand again two weeks after surgery by a physician who was unawareof the group assignments. Wounds were suspected of being infectedwhen pus could be expressed from the surgical incision or aspiratedfrom a loculated mass inside the wound. Samples of pus wereobtained and cultured for aerobic and anaerobic bacteria, andwounds were considered infected when the culture was positivefor pathogenic bacteria. All the wound infections diagnosedwithin 15 days of surgery were included in the data analysis.
Wound healing and infections were also evaluated by the ASEPSISsystem,28 in which a score is calculated as the weighted sumof points assigned to the following factors: the duration ofantibiotic administration, the drainage of pus during localanesthesia, the débridement of the wound during generalanesthesia, the presence of a serous discharge, the presenceof erythema, the presence of a purulent exudate, the separationof deep tissues, the isolation of bacteria from fluid dischargedfrom the wound, and a duration of hospitalization exceeding14 days. Scores exceeding 20 on this scale indicate wound infection.As an additional indicator of infection, preoperative differentialwhite-cell counts were compared with counts obtained on postoperativedays 1, 3, and 6.
Collagen deposition in the wound was evaluated in a subgroupof 30 patients in the normothermia group and 24 patients inthe hypothermia group. A 10-cm expanded polytetrafluoroethylenetube (Impra, International Polymer Engineering, Tempe, Ariz.)was inserted subcutaneously several centimeters lateral to theincision at the completion of surgery. On the seventh postoperativeday, the tube was removed and assayed for hydroxyproline, ameasure of collagen deposition.29 The ingrowth of collagen insuch tubes is proportional to the tensile strength of the healingwound 29 and the subcutaneous oxygen tension.22
Statistical Analysis
Outcomes were evaluated on an intention-to-treat basis. Thenumber of postoperative wound infections in each study groupand the proportion of smokers among the infected patients wereanalyzed by Fisher's exact test. Scores for wound healing, thenumber of days of hospitalization, the extent of collagen deposition,postoperative core temperatures, and potential confounding factorswere evaluated by unpaired, two-tailed t-tests. Factors thatpotentially contributed to infection were included in a univariateanalysis. Those that correlated significantly with infectionwere then included in a multivariate logistic regression withbackward elimination; a P value of less than 0.25 was requiredfor a factor to be retained in the analysis.
All the results are presented as means ±SD. A P valueof less than 0.01 was required to indicate a significant differencein our major outcomes (the incidence of infection and the durationof hospitalization); a P value of less than 0.005 was consideredto indicate a significant difference in postoperative temperature(to compensate for multiple comparisons); for all other data,a P value of less than 0.05 was considered to indicate a statisticallysignificant difference.
Results
Patients were enrolled in the study from July 1993 through March1995; 155 were evaluated at the University of Vienna, 30 atthe University of Graz, and 15 at Rudolfstiftung Hospital. Accordingto the investigational protocol, the study was stopped after200 patients were enrolled, because the incidence of surgical-woundinfection in the two study groups differed with an alpha levelof less than 0.01. One hundred four patients were assigned tothe normothermia group, and 96 to the hypothermia group. Anaudit confirmed that the patients had been properly assignedto the groups and that the slight disparity in numbers was presentin the original computer-generated randomization codes. Allthe patients allowed their wounds to be evaluated daily duringhospitalization. Ninety-four percent returned for the two-weekclinic visit after discharge; those who did not were evenlydistributed between the study groups and mostly returned tovisit the private offices of their attending surgeons. The woundstatus of these patients was determined by calling the physician.No previously unidentified wound infections were detected inthe clinic for the first time.
Table 1 shows that the characteristics, diagnoses, types ofsurgical procedure, duration of surgery, hemodynamic values,and types of anesthesia of the patients in the two study groupswere similar. Nor did smoking status, the results of preoperativelaboratory tests, or preoperative laboratory values differ significantlybetween the groups. The patients assigned to hypothermia requiredmore transfusions of allogeneic blood (P = 0.01). Intraoperativevasoconstriction was observed in 74 percent of the patientsassigned to hypothermia but in only 6 percent of those assignedto normothermia (P<0.001). Core temperatures at the end ofsurgery were significantly lower in the hypothermia group thanin the normothermia group (34.7±0.6 vs. 36.6±0.5°C,P<0.001), and they remained significantly different for morethan five hours postoperatively (Figure 1).
Figure 1. Core Temperatures during and after Colorectal Surgery in the Study Patients.
The mean (±SD) final intraoperative core temperature was 34.7±0.6°C in the 96 patients assigned to hypothermia, who received routine thermal care, and 36.6±0.5°C in the 104 patients assigned to normothermia, who were given extra warming. The core temperatures in the two groups differed significantly at each measurement, except before the induction of anesthesia (first measurement) and after six hours of recovery.
Postoperative vasoconstriction was observed in 78 percent ofthe patients in the hypothermia group; the vasoconstrictioncontinued throughout the six-hour recovery period. In contrast,vasoconstriction, usually short-lived, was observed in only22 percent of the patients in the normothermia group (P<0.001).Shivering was observed in 59 percent of the hypothermia group,but in only a few patients in the normothermia group. Thermalcomfort was significantly greater in the normothermia groupthan in the hypothermia group (score on the visual-analoguescale one hour after surgery, 73±14 vs. 35±17mm). The difference in thermal comfort remained statisticallysignificant for three hours. Pain scores and the amount of opioidadministered were virtually identical in the two groups at everypostoperative measurement; hemodynamic values were also similar.
The overall incidence of surgical-wound infection was 12 percent.Although the SENIC and NNISS scores for the risk of infectionwere similar in the two groups, there were only 6 surgical-woundinfections in the normothermia group, as compared with 18 inthe hypothermia group (P = 0.009) (Table 2). Most positive culturescontained several different organisms; the major ones were E.coli (11 cultures), S. aureus (7), pseudomonas(4), enterobacter(3), and candida(3). Culture-negative pus was expressed fromthe wounds of two patients assigned to hypothermia and one patientassigned to normothermia. The ASEPSIS scores were higher inthe hypothermia group than in the normothermia group (13±16vs. 7±10, P = 0.002) (Table 2); these scores exceeded20 in 32 percent of the former but only 6 percent of the latter(P<0.001).
Table 2. Postoperative Findings in the Two Study Groups.
In a univariate analysis, tobacco use, group assignment, surgicalsite, NNISS score, SENIC score, need for transfusion, and agewere all correlated with the risk of infection. In a multivariatebackward-elimination analysis, tobacco use, group assignment,surgical site, NNISS score, and age remained risk factors forinfection (Table 3).
Table 3. Multivariate Analysis of Risk Factors for Surgical-Wound Infection.
Four patients in the normothermia group and seven in the hypothermiagroup required admission to the intensive care unit (P = 0.47),mainly because of wound dehiscence, colon perforation, and peritonitis.Two patients in each group died during the month after surgery.The incidence of infection was similar at each study hospital,and no one surgeon was associated with a disproportionate numberof infections.
Table 2 shows that significantly more collagen was depositednear the wound in the patients in the normothermia group thanin the patients in the hypothermia group (328±135 vs.254±114 µg per centimeter). The patients assignedto hypothermia were first able to tolerate solid food one daylater than those assigned to normothermia (P = 0.006); similarly,the sutures were removed one day later in the patients assignedto hypothermia (P = 0.002). The duration of hospitalizationwas 12.1±4.4 days in the normothermia group and 14.7±6.5days in the hypothermia group (P = 0.001). This difference wasstatistically significant even when the analysis was limitedto the uninfected patients. In the normothermia group, the durationof hospitalization was 11.8±4.1 days in patients withoutinfection and 17.3±7.3 days in patients with infection(P = 0.003). In the hypothermia group the duration of hospitalizationwas 13.5±4.5 days in patients without infection and 20.7±11.6days in patients with infection (P<0.001).
The postoperative hemoglobin concentrations did not differ significantlybetween the two groups (Table 1). On the first postoperativeday, leukocytosis was impaired in the hypothermia group as comparedwith the normothermia group (white-cell count, 11,500±3500vs. 13,400±2500 cells per cubic millimeter; P<0.001).On the third postoperative day, however, white-cell counts weresignificantly higher in the hypothermia group (10,100±3900vs. 8900±29 00 cells per cubic millimeter). The differencein values on the third day was not statistically significantwhen only uninfected patients were included in the analysis.By the sixth postoperative day, the white-cell counts were similarin the two groups.
Among smokers, the number of cigarettes smoked per day was similarin the two groups (22±20 in the hypothermia group vs.22±14 in the normothermia group). The morphometric characteristics,anesthetic care, and SENIC and NNISS scores of smokers and nonsmokerswere not significantly different. Nonetheless, the proportionof patients with wound infection was significantly higher amongsmokers (23 percent, or 14 of 62) than among nonsmokers (7 percent,or 10 of 138; P = 0.004). Furthermore, the length of hospitalizationwas significantly greater among smokers (14.9±6.7 days,vs. 12.9±5.0 days among nonsmokers; P = 0.02) (Table 4).
Table 4. Postoperative Findings in the Study Patients According to Smoking Status.
Discussion
The initial hours after bacterial contamination are a decisiveperiod for the establishment of infection.25 In surgical patients,perioperative factors can contribute to surgical-wound infections,but the infection itself is usually not manifest until dayslater.
In our study, forced-air warming combined with fluid warmingmaintained normothermia in the treated patients, whereas theunwarmed patients had core temperatures approximately 2°Cbelow normal.8 Perioperative hypothermia persisted for morethan four hours and thus included the decisive period for establishingan infection.25,30 The patients with mild perioperative hypothermiahad three times as many culture-positive surgical-wound infectionsas the normothermic patients. Moreover, the ASEPSIS scores showedthat in the patients assigned to hypothermia the reduction inresistance to infection was twice that in the normothermia group.
The types of bacteria cultured from our patients' surgical woundswere similar to those reported previously.2,3 These organismsare susceptible to oxidative killing, which is consistent withour hypothesis that hypothermia inhibits the oxidative killingof bacteria.31 The overall incidence of infection in our studywas approximately 35 percent higher than in previous reports.3One explanation for this relatively high incidence is that weconsidered all wounds draining pus that yielded a positive cultureto be infected, although some may have been of minor clinicalimportance. The hospitalizations of infected patients were oneweek longer than those of patients without surgical-wound infections,however, indicating that most infections were substantial. Similarprolongation of hospitalization has been reported previously.1,2
It is interesting to note that hospitalization was also prolonged(by about two days) in the uninfected patients in the hypothermiagroup (Table 2). A number of factors influenced the decisionto discharge patients, but healing of the incision (formationof a "healing ridge," for example) was among the most important.As is consistent with a delay in clinical healing, sutures wereremoved significantly later and the deposition of collagen (anindex of scar formation and the strength of the healing wound)was significantly less in the hypothermia group than in thenormothermia group. That the patients assigned to hypothermiarequired significantly more time before they could toleratesolid food is also consistent with impaired healing.
In Austria's medical system, administrative factors and costsof hospitalization do not influence the length of stay in thehospital. No data on individual costs are tabulated by the participatinghospitals, and they are therefore not available for our patients.Nonetheless, the cost of a prolonged hospitalization must exceedthe cost of fluid and forced-air warming (approximately $30in the United States). In a managed-care situation, the durationof hospitalization might have differed less, or not at all.However, our data suggest that patients kept at normal temperaturesduring surgery would be better prepared for discharge at a fixedtime than those allowed to become hypothermic.
Among all 200 patients in our study, those who smoked had threetimes more surgical-wound infections and significantly longerhospitalizations than the nonsmokers. Similar data have beenreported previously.32 Numerous factors contributed to theseresults; one may have been that smoking markedly lowers oxygentension in tissue for nearly an hour after each cigarette.33(Thermoregulatory vasoconstriction produces a similar reduction.34)The distribution of factors known to influence infection wassimilar between smokers and nonsmokers, but the smokers mayhave had other behavioral or physiologic factors predisposingthem to infection.
The prevalence of smoking was similar in the two study groups.Other factors may have influenced the patients' susceptibilityto wound infections, such as arterial hypoxemia, hypovolemia,the concentration of the anesthetic used, and vasoconstrictionresulting from pain-induced stress.25,26,35,36 However, theadministration of oxygen, oxyhemoglobin saturation, fluid balance,hemodynamic responses, end-tidal concentrations of anesthetic,pain scores, and quantities of opioid administered were allsimilar between the two groups. These factors are thereforenot likely to have confounded our results. It is also unlikelythat exaggerated bacterial growth aggravated the infectionsin the hypothermia group, because small reductions in temperatureactually decrease growth in vitro.37
Mild hypothermia can increase blood loss and the need for transfusionduring surgery.38 In vitro studies suggest that perioperativehypothermia may aggravate surgical bleeding by impairing thefunction of platelets and the activity of clotting factors.39,40Blood transfusions may increase susceptibility to surgical-woundinfections by impairing immune function.41 Our patients assignedto hypothermia required significantly more allogeneic bloodto maintain postoperative hemoglobin concentrations than didthe patients assigned to normothermia. However, we administeredonly leukocyte-depleted blood, and multivariate regression analysisindicated that a requirement for transfusion did not independentlycontribute to the incidence of wound infection. It is thus unlikelythat the differences in the incidence of infection in the twogroups we studied resulted from transfusion-mediated immunosuppression.
In summary, this double-blind, randomized study indicates thatintraoperative core temperatures approximately 2°C belownormal triple the incidence of wound infection and prolong hospitalizationby about 20 percent. Maintaining intraoperative normothermiais thus likely to decrease infectious complications and shortenhospitalization in patients undergoing colorectal surgery.
Supported in part by grants (GM49670 and GM27345) from the NationalInstitutes of Health, by the Joseph Drown and Max Kade Foundations,and by Augustine Medical, Inc. The authors do not consult for,accept honorariums from, or own stock or stock options in anycompany whose products are related to the subject of this research.
We are indebted to Heinz Scheuenstahl for the collagen-depositionanalysis; to Helene Ortmann, M.D., Andrea Hubacek, M.D., MichaelZimpfer, M.D., and Gerhard Pavecic for their generous assistance;and to Mallinckrodt Anesthesiology Products, Inc., for the donationof thermometers and thermocouples.
* The study investigators are listed in the Appendix.
Source Information
From the Thermoregulation Research Laboratory and the Department of Anesthesia, University of California, San Francisco (A.K., D.I.S.); and the Departments of Anesthesiology and General Intensive Care, University of Vienna, Vienna, Austria (A.K., D.I.S., R.L.). Presented in part at the International Symposium on the Pharmacology of Thermoregulation, Giessen, Germany, August 17–22, 1994, and at the Annual Meeting of the American Society of Anesthesiologists, Atlanta, October 21–25, 1995.
Address reprint requests to Dr. Sessler at the Department of Anesthesia, 374 Parnassus Ave., 3rd Fl., University of California, San Francisco, CA 94143-0648.
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Appendix
The following investigators also participated in this study:patient safety and data auditing: H.W. Hopf and T.K. Hunt (Universityof California, San Francisco); site directors: G. Polak (HospitalRudolfstiftung, Vienna, Austria) and W. Kröll (Universityof Graz, Graz, Austria); patient care: F. Lackner and R. Fuegger(University of Vienna); data acquisition: E. Narzt (Universityof Vienna), C. Wolrab (University of Vienna), E. Marker (Universityof Vienna), A. Bekar (Orthopedic Hospital, Speising, Vienna),H. Kaloud (University of Graz), U. Stratil (Hospital Rudolfstiftung),and R. Csepan (University of Vienna); wound evaluation: V. Goll(University of Vienna), G.S. Bayer (University of Vienna), andP. Steindorfer (University of Graz); and data management: B.Petschnigg (University of Vienna).
Perioperative Normothermia and Surgical-Wound Infection
Benzer A., Sparr H. J., Kempen P. M., Osler T., Rogers F., Fletcher D., Schein M., Rucinski J., Wise L., Winfree C. J., Baker K. Z., Connolly E. S., Sessler D. I., Kurz A.
Extract |
Full Text
N Engl J Med 1996;
335:747-750, Sep 5, 1996.
Correspondence
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