| Hypothermia Induced by Incorrect Monitoring of Core Temperature: A case report. |
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Young Jun Bahn, Hye Won Shin, Hye Won Lee, Hae Ja Lim, Suk Min Yoon, Seong Ho Chang |
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Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea. hwshin99@yahoo.com |
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| Abstract |
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A 55-year-old man was scheduled to undergo revisional total hip arthroplasty under general anesthesia. During the operation, a warm blanket and fluid warmer were applied, with his body temperature maintained at 35oC, as assessed with the use of a temporal-artery thermometer. In the course of the operation, severe bleeding developed, which required a massive transfusion of packed red blood cells and other blood components to correct the electrolyte and pH balances; the infusion of cardiovascular drugs was also preformed.
However, the hemodynamic status of the patient deteriorated to severe hypotension, with atrial fibrillation, non-sustaining paroxysmal ventricular tachycardia and ventricular fibrillation. The patient was re-evaluated, and it was realized the temporal-artery thermometer had been incorrectly monitored, causing hemodynamic deterioration, which was assessed as hypothermia from a nasopharyngeal temperature of 29 degrees C. Active warming methods, including a condensed humidifier, and warming of the fluids and blood compounds with a rapid infusion system, were instigated, resulting in stabilization of the patient's hemodynamic status and the disappearance of his dysrhythmia. |
| Key Words:
hypothermia; temperature monitoring; temporal-artery thermometer |
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