Hypothermia Induced by Incorrect Monitoring of Core Temperature: A case report.
10.4097/kjae.2006.50.2.217
- Author:
Young Jun BAHN
1
;
Hye Won SHIN
;
Hye Won LEE
;
Hae Ja LIM
;
Suk Min YOON
;
Seong Ho CHANG
Author Information
1. Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea. hwshin99@yahoo.com
- Publication Type:Case Report
- Keywords:
hypothermia;
temperature monitoring;
temporal-artery thermometer
- MeSH:
Anesthesia, General;
Arthroplasty, Replacement, Hip;
Atrial Fibrillation;
Body Temperature;
Cardiovascular Agents;
Erythrocytes;
Hemodynamics;
Hemorrhage;
Humans;
Hydrogen-Ion Concentration;
Hypotension;
Hypothermia*;
Middle Aged;
Tachycardia, Ventricular;
Thermometers;
Ventricular Fibrillation
- From:Korean Journal of Anesthesiology
2006;50(2):217-220
- CountryRepublic of Korea
- Language:Korean
-
Abstract:
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.
