Arch Orthop Trauma Surg DOI 10.1007/s00402-015-2246-2
ARTHROSCOPY AND SPORTS MEDICINE
Effect of irrigation fluid temperature on core body temperature and inflammatory response during arthroscopic shoulder surgery Xiaoyun Pan1 • Luyou Ye1 • Zhongtang Liu2 • Hong Wen1 • Yuezheng Hu1 Xinxian Xu1
•
Received: 14 February 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose This study was designed to evaluate the influence of irrigation fluid on the patients’ physiological response to arthroscopic shoulder surgery. Methods Patients who were scheduled for arthroscopic shoulder surgery were prospectively included in this study. They were randomly assigned to receive warm arthroscopic irrigation fluid (Group W, n = 33) or room temperature irrigation fluid (Group RT, n = 33) intraoperatively. Core body temperature was measured at regular intervals. The proinflammatory cytokines TNF-a, IL-1, IL-6, and IL-10 were measured in drainage fluid and serum. Results The changes of core body temperatures in Group RT were similar with those in Group W within 15 min after induction of anesthesia, but the decreases in Group RT were significantly greater after then. The lowest temperature was 35.1 ± 0.4 °C in Group RT and 35.9 ± 0.3 °C in Group W, the difference was statistically different (P \ 0.05). Hypothermia occurred in 31 out of 33 subjects in Group RT (31/33; 94 %), but was significantly lower in Group W (9/24; 27 %; P \ 0.05). Serum TNF-a changes were undetectable postoperatively. No statistical significant differences in serum IL-1 and serum IL-10 levels were observed between groups. Serum IL-6 levels were significantly lower in Group W (P \ 0.05). The levels
X. Pan and L. Ye have contributed equally to this study. & Xinxian Xu [email protected] 1
The Osteopathy Department, The Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
2
The Osteopathy Department, The Changhai Hospital, Second Military Medical University, Shanghai, China
of the above cytokines in drainage fluid were all significantly lower in Group W after surgery (P \ 0.05). Conclusion Hypothermia occurs more often in arthroscopic shoulder surgery by using room temperature irrigation fluid compared with warm irrigation fluid. And local inflammatory response is significantly reduced by using warm irrigation fluid. It seems that warm irrigation fluid is more recommendable for arthroscopic shoulder surgery. Keywords Arthroscopic Shoulder surgery Hypothermia Proinflammatory cytokines
Introduction Arthroscopic technology is widely used in clinical diagnosis and treatment of shoulder disorders. In this type of surgery, large volumes of irrigation fluid are used to dilate the operating field and usually maintained at room temperature. Because the shoulder is not a closed anatomical space and located close to the core body structure, a lot of fluid will leak out and reach the chest, which may lead to a vast temperature variation [8, 9]. Then core temperature will drop and hypothermia may appear. Perioperative hypothermia, defined as core temperature less than 36 °C, is a common occurrence during the surgery. Many factors, such as low ambient temperature, long length of anesthesia, massive blood loss, and excess intravenous fluid, could increase the incidence [1]. It should be avoided whenever possible as numerous complications may arise, including increased risk of postoperative cardiovascular accident [2], increased risk of wound infection [3], prolonged duration of anesthesia recovery [4], increased incidence of postoperative shivering [5], and coagulopathy [6], so timely interventions are necessary. To
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date, to decrease the incidence of hypothermia during arthroscopic shoulder surgery, many protocols have been created [7], among which the application of warmed irrigation fluid is a good choice. Several published reports supported that warm irritation fluid (36 °C) is an efficient measure in reducing the occurrence of perioperative hypothermia during arthroscopic shoulder surgery [8, 9]. Surgery is a controlled trauma with immunologic consequences [10]. Compared with warm irrigation fluid, room-temperature irrigation fluid is a local physical stimulus to the body [11]. As an acute stressor, it may have its unique characteristic of neuroendocrine changes because the accompanying temperature variations may affect immune system. Inflammatory cytokines, which mainly produced at the trauma site, plays an important role in eliciting this systemic stress response [12]. As a heterogeneous group of soluble short-acting glucoproteins, inflammatory cytokines are released by cells of immune system and involved in the regulation of immune and inflammatory response [13, 14]. Normally, the absolute amounts of cytokine production are very low, which limits their actions to the local tissues. However, under stress conditions, excessive amounts would be released and could overspill into the systemic circulation rapidly. It has been reported that many proinflammatory cytokines, such as TNF-a, IL-1, IL-6, significantly increased under cold stress [15, 16]. And this production could induce the up-regulation of anti-inflammatory cytokines, such as IL-4 and IL-10, which could decrease the severity of inflammatory response [17, 18]. This inflammatory response is proportional to the severity of surgical trauma. It was reported that this sequence of steps was associated with multiple organ-system dysfunction and mortality postoperatively [19, 20]. For local structure like shoulder and knee joint, this response is concerned with regional pain and joint effusion [21]. Despite this, there is still no study on the relationship between the temperature of irrigation fluid and the levels of inflammatory cytokines during arthroscopic shoulder surgery. We therefore conducted this study to determine whether the core body temperature and the levels of perioperative inflammatory cytokines were changed with different temperatures of irrigation fluid. Our hypothesis was that warm irrigation fluid during arthroscopic shoulder surgery can decrease perioperative hypothermia and inflammatory response.
Patients and methods Study design Between November 2012 and May 2013, we conducted this randomized, open-label, controlled clinical study at our
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department. Patients who were scheduled for arthroscopic shoulder surgery were prospectively included in this study. They were randomly assigned to receive warm irrigation fluid or room-temperature irrigation fluid during the surgery. Core body temperature was measured perioperatively. Inflammatory cytokines in drainage fluid and serum were measured postoperatively. And adverse events were recorded. This protocol was approved by the Institutional Review Board of Wenzhou Medical University before initiating. It was conducted in accordance with the Helsinki Declaration and in compliance with the Good Clinical Practice Guidelines. Each participant gave informed written consent before entry into this study. Patients Of 86 eligible patients, 8 were excluded because of incomplete data. The remaining 78 between 27- and 73-year old were available for further tracking study. All of them were free of severe chronic medical diseases or chronic disabling diseases that could not tolerate surgical management. We also excluded patients with massive rotator cuff tears or previous operations on the same shoulder, as well as those require external warming devices before or during surgery. Finally, 66 subjects met all of the eligibility criteria and were randomly allocated to receive warm irrigation fluid (Group W, n = 33) or room-temperature irrigation fluid (Group RT, n = 33) by using a random number table generated by computer. Preoperative preparation The temperature of the operating room was automatically maintained at 21 °C. All intravenous fluids were administered at room temperature and given without inline warming. All patients were covered with two layers of surgical drapes during the surgery and one cotton blanket over the entire body postoperatively. In our study, normal saline in a 3-L bag without any other additional agent was used as the irrigation fluid. The patients in Group RT received irrigation fluid maintained at 21 °C, and those in Group W received the fluid with a temperature of 36 °C. All irrigation fluid was pre-warmed and kept by using the same electrical heating tank (Fuyilian, Beijing, China), and was delivered with a pressurecontrolled pump set to 60 mmHg. In additional, all normal saline bags were put into a Styrofoam box, and a digital thermometer was placed for real-time temperature monitoring at the same time. Vital signs, including pulse, blood pressure, and respiratory rate were monitored continuously throughout the operation. General anesthesia was required for all patients
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and all procedures were completed by the same senior anesthesiologist. After induction of general anesthesia, an esophageal temperature probe (Mon-a-therm, TycoMallinckrodt Anesthesiology Products, St. Louis, MO) was inserted to monitor the core body temperature, which was recorded at 15-min intervals during the operation.
TNF-a, IL-1, IL-6, and IL-10 levels in drainage fluid and serum were measured using ELISA kits from Bio-Tech (Shanghai, China), according to the manufacturer,s instructions.
Surgical procedures
All statistical tests for related measurement and count data were two-sided and evaluated at a 5 % level of significance. The statistical significance of differences of continuous data such as core temperature score, VAS score, and level of inflammatory cytokines was assessed by using an independent t test. And dichotomous variables such as the incidences of hypothermia, shivering, and AE were compared by use of Chi-square test or Fisher exact test. All statistical analyses were performed with SPSS software (Version 19.0; SPSS, Chicago, IL).
All the arthroscopic surgeries were performed by the same senior surgeon. Following induction of general anesthesia, the patient was placed in the lateral decubitis position. Except 12 cases of flat type of acromion checked on preoperative radiograph, subacromial decompression with acromioplasty was performed in 54 cases. Biceps tenotomy was performed in 27 cases, including 16 with a symptomatic biceps tear greater than 50 % and 11 with unstable biceps. After adequate visualization, preparation, and exposure, the torn cuffs were repaired by using singleor double-row technology according to tear size and degeneration grade. Finally, a standard polyvinyl chloride suction drain with an external of 2 mm was placed into the shoulder joint from the lateral portal. Then the drain was tied and a negative pressure absorbing ball was connected. Data collection After operation, all patients were sent to PACU for further assessment. The room temperature was still maintained at 21 °C, and core body temperature was measured at 15-min intervals for 1 hour. Other crucial indicators, including length of anesthesia, length of surgery, amount of intravenous fluid, and amount of irrigation fluid were all recorded. Adverse events (AEs), such as postoperative shivering, vomiting, headache, and cardiovascular events were also closely monitored. Blood hemoglobin level, weight, and pain measure with visual analog scale (VAS) were rechecked on the first day postoperatively. Detection of inflammatory cytokines At hours 0, 3, and 6 postoperatively, the drainage fluid from the suction drain was obtained with the help of an abacterial syringe. All samples were put on ice and taken to the laboratory promptly, where they were firstly centrifuged at 15009g, for 15 min at 4 °C. Then the supernatants were isolated and centrifuged again at 30009g for next 15 min. After twice centrifugation, the final supernatants were aliquoted and frozen at -80 °C before further analyses. Meanwhile, whole blood was drawn at 6, 12, and 24 h after surgery. Serum was obtained from the whole blood and also stored at -80 °C.
Statistical method
Results All data were gathered and analyzed by the same statistician. The baseline demographic characteristics and clinical data are shown in Table 1. Age distribution was an average of 48.0 years and BMI was 25.2 kg/m2. No significant differences in initial core body temperature, preoperative VAS score, and preoperative hemoglobin level were observed, as well as in total intravenous fluid, total irrigation fluid, and mean irrigation fluid perioperatively. The length of surgery, ranged from 61 to 149 min, was 92.1 ± 21.2 min in Group RT, which was not significantly different from that in Group W (93.8 ± 25.9; P [ 0.05). The length of anesthesia in Group RT and Group W were 142.8 ± 20.1 and 145.6 ± 26.2 min, respectively, which was also not significant (P [ 0.05). The performances of arthroscopic procedures were similar between the two groups. Specifically, 30 (91 %) subjects in Group RT and 24 (72 %) in Group W received acromioplasty, 12 (36 %) in Group RT and 15 (46 %) in Group W received biceps tenotomy, and 14 (42 %) in Group RT and 11 (33 %) in Group W received double-row rotator cuff repair. The core body temperatures of both groups had clear and early decreases after anesthesia induction, which went down linearly within 75 min and stayed stable in the following period. And both increased gradually in recovery stage (Fig. 1). The changes in Group RT were similar with those in Group W within 15 min, but significantly greater after then, which penetrated the following period and persisted throughout 1 h after anesthesia. The lowest temperature, which was obtained in 90 min during anesthesia, was 35.1 ± 0.4 °C in Group RT and 35.9 ± 0.3 °C in Group W. Their difference was statistically different
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Arch Orthop Trauma Surg Table 1 Demographic characteristics and clinical data Age (year)
Group RT (n = 33)
Group W (n = 33)
49.2 ± 11.8
47.6 ± 10.3
Gender
0.554 0.612
Male
11
Female
22
19
24.7 ± 3.2
25.7 ± 3.1
Body mass index (BMI) (kg/m2)
P
14 0.209
Initial core body temperature (°C)
36.6 ± 0.3
36.5 ± 0.3
0.668
Preoperative VAS score
6.8 ± 1.4
7.1 ± 1.2
0.312 0.820
Preoperative hemoglobin level (g/dl)
14.0 ± 1.2
14.1 ± 0.9
Length of surgery (min)
92.1 ± 21.2
93.8 ± 25.9
0.780
Length of anesthesia (min)
142.8 ± 20.1
145.6 ± 26.2
0.626
Total intravenous fluid (ml)
607.6 ± 269.3
620.6 ± 265.1
0.844
Total irrigation fluid (L)
11.2 ± 2.9
11.6 ± 3.3
0.669
Mean irrigation fluid (L/h)
7.2 ± 0.5
7.4 ± 04
0.178
Operating room temperature (°C)
20.8 ± 0.5
21.0 ± 0.6
0.154
Arthroscopic procedures Acromioplasty
0.108
Yes
30
24
No
3
9
Yes
12
15
No
21
18
Single row
19
22
Double row
14
11
Biceps tenotomy
0.617
Rotator cuff repair
0.612
Fig. 1 Changes of core temperature during the operations in Group RT and Group W. *P \ 0.05, Group RT vs. Group W (OR, operation room)
(P \ 0.05). Hypothermia was observed in both groups (Table 2). It occurred in 31 out of 33 subjects in Group RT (31/33; 94 %), whereas this marker was much lower in Group W (9/24; 27 %; P \ 0.05). All drainage tubes were removed at 24 h postoperatively and the amount of drainage fluid was recorded. The total volume was 11.3 ± 4.4 ml in Group RT and 10.8 ± 4.2 ml in Group W, there was no significant difference between them (P [ 0.05) (Table 2). In addition, no
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intergroup differences were noted in hemoglobin decreases and VAS scores at 6 h and 3 days postoperatively (Table 2). The inflammatory cytokines in serum were measured at 6 h preoperatively and 6, 12, and 24 h postoperatively. In addition, local production of these indicators was evaluated in drainage fluid at 0, 2, 6 h after surgery. Tables 3 and 4 summarize serum and drainage fluid levels of TNF-a, IL-1, IL-6, and IL-10. TNF-a levels were undetectable in serum,
Arch Orthop Trauma Surg Table 2 Clinical Data perioperatively
Group RT (n = 33)
Group W (n = 33)
Yes
31 (0.94)
9 (0.27)
No
2
24
11.3 ± 4.4
10.8 ± 4.2
Hypothermia
Total drainage fluid (ml)
P 0.000*
0.619
Hemoglobin decrease (g/dl) 6 h postoperatively
1.3 ± 0.9
1.5 ± 0.7
0.355
3 days postoperatively
0.1 ± 0.6
0.2 ± 0.6
0.403
VAS score 6 h postoperatively
4.0 ± 1.1
4.6 ± 1.4
0.087
3 days postoperatively
3.1 ± 1.3
3.2 ± 1.2
0.842
AEs Shivering, [n (%)]
14 (42)
1 (3)
0.000*
Vomiting, [n (%)]
0 (0)
1 (3)
1.000
Nausea, [n (%)]
3 (9)
1 (3)
0.613
Dizziness, [n (%)] Headache, [n (%)]
8 (24) 3 (9)
5 (15) 2 (6)
0.537 1.000
but were measurable in drainage fluid. As shown in Fig. 2, continuing increases in local production could be observed in both groups from 0 to 6 h postoperatively, and the levels in Group RT were significantly higher (P \ 0.05). Serum IL-1 levels did not differ between the two groups at any time (P [ 0.05). Drainage fluid IL-1 levels are depicted in Fig. 3. Similar to TNF-a, IL-1 levels increased continuously from 0 to 6 h postoperatively, and the levels of this indictor were significantly lower in Group W after surgery (P \ 0.05). Serum and drainage fluid IL-6 levels are described in Figs. 4 and 5. In both groups, the serum levels are highest at 6 h and downward trends could be observed after this point, and the differences between preoperative and postoperative levels were all significant (P \ 0.05). There was no significant difference between
groups preoperatively (P [ 0.05). However, after surgery, the levels in Group RT were all significantly higher (P \ 0.05). Continuing increases in drainage fluid could be observed in both groups, and also significant higher levels were observed in Group RT (P \ 0.05). For IL-10, its changes were similar to IL-1. Specially, no significant changes between groups and between preoperative and postoperative levels in serum were observed (P [ 0.05). For their drainage fluid levels described in Fig. 6, though no statistical difference was observed at 0 h (P [ 0.05), they were significantly lower in Group W at 2 and 6 h (P \ 0.05). Higher mean postoperative VAS scores were obtained in room temperature fluid irrigation group 6 h postoperatively. Shivering was observed in 14 patients in Group
Table 3 The inflammatory cytokines levels in serum Preoperative (pg/ml)
6 h postoperatively (pg/ml)
12 h postoperatively (pg/ml)
24 h postoperatively (pg/ml)
Group W
0
0
0
0
Group RT
0
0
0
0
5.6 ± 2.3 6.8 ± 3.1
6.0 ± 2.5 6.3 ± 2.8
5.1 ± 2.9 6.2 ± 3.3
5.9 ± 3.3 5.8 ± 2.9
TNF-a
IL-1 Group W Group RT IL-6 Group W
19.2 ± 8.3*
109.9 ± 23.4*
95.3 ± 21.6*
73.5 ± 24.0*
Group RT
17.2 ± 7.1
137.2 ± 30.7
130.6 ± 24.9
93.3 ± 24.9
IL-10 Group W
3.6 ± 2.0
4.3 ± 2.6
5.1 ± 2.4
4.3 ± 2.4
Group RT
2.8 ± 1.7
4.9 ± 2.9
5.6 ± 2.1
4.4 ± 2.6
* P \ 0.05, Group W vs. Group RT
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Arch Orthop Trauma Surg Table 4 The inflammatory cytokines levels in drainage fluid
0 h postoperatively (pg/ml)
2 h postoperatively (pg/ml)
6 h postoperatively (pg/ml)
TNF-a Group W
74.2 ± 18.4*
Group RT
93.0 ± 23.8
114.1 ± 21.8
95.8 ± 18.1*
139.6 ± 24.0
101.5 ± 21.7*
Group W
119.3 ± 32.0*
169.9 ± 34.6*
180.8 ± 46.1*
Group C
141.1 ± 39.7
194.7 ± 44.3
212.2 ± 34.6
IL-1
IL-6 Group W
6543.6 ± 1333.2*
Group C
7817.0 ± 1645.8
9960.0 ± 1225.2* 11,504.2 ± 1590.4
10,161.2 ± 1268.2* 11,890.4 ± 1574.8
IL-10 Group W
196.0 ± 56.2
367.0 ± 58.1*
450.5 ± 53.8*
Group C
210.7 ± 63.6
448.9 ± 58.2
515.7 ± 63.4
* P \ 0.05, Group W vs. Group RT
Fig. 2 TNF-alevels in drainage fluid, mean ± standard error of the mean. *P \ 0.05, Group W vs. Group RT
Fig. 4 IL-6 levels in serum, mean ± standard error of the mean. *P \ 0.05, Group W vs. Group RT. #P \ 0.05, postoperative values vs. perioperative values
Fig. 3 IL-1 levels in drainage fluid, mean ± standard error of the mean. *P \ 0.05, Group W vs. Group RT
Fig. 5 IL-6 levels in drainage fluid, mean ± standard error of the mean. *P \ 0.05, Group W vs. Group RT
RT (14/33, 42 %) at recovery stage, but only 1 patient experienced shivering in Group W (1/33; 3%; P \ 0.05). A total of 14 (42 %) patients reported at least one AE except
for Shivering, but no serious AE such as heart failure or cerebrovascular accident occurred. The proportions did not differ according to treatment group (P [ 0.05).
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Fig. 6 IL-10 levels in drainage fluid, mean ± standard error of the mean. *P \ 0.05, Group W vs. Group RT
Discussion Perioperative hypothermia is a common symptom during anesthesia and surgery [22]. Mild hypothermia may be beneficial, as it can reduce metabolic rate and oxygen consumption, and increase tolerance of organs and tissues to hypoxia and ischemia [24, 25]. But a long lasting or severe one should be avoided because its potential complications could adversely influence the surgical effectiveness [23, 24, 26]. As large volumes of roomtemperature irrigation fluid are used, patients undergoing arthroscopic shoulder surgery are particularly prone to hypothermia [27]. However, there are few studies that focus on this tissue and conflicting opinions are worth mentioning. Board T N et al. carried out a clinical study on 24 patients undergoing arthroscopic subacromial decompression. In their study, the patients received room temperature (22 °C) or warmed (36 °C) irrigation fluid during the surgery. The authors found that the incidence of hypothermia was significantly higher when using room temperature fluid, and concluded that core temperature may be influenced by irrigation fluid temperature [8]. In another study performed by Kim et al., 50 cases undergoing arthroscopic shoulder surgery were randomly allocated to receive either room temperature or warmed irrigation fluid (37–39 °C). During the surgery, the mean maximum drop in the room temperature fluid group and the warmed fluid group was 0.86 ± 0.2 and 0.28 ± 0.2 °C, respectively (P \ 0.001). They concluded that hypothermia occurred more often with room-temperature irrigation fluid [9]. But on the contrary, Joo Han et al. showed that irrigation fluid temperature was not a factor responsible for altering the core body temperature in this type of surgery [28]. In our study, we found that large volumes of room-temperature irrigation fluid could cause significant drops in core body temperature during arthroscopic shoulder surgery, while warm irrigation fluid could markedly reduce the drops,
which was similar with the outcomes reported by Board T N and Kim et al. [8, 9]. What was more, in both groups, the decrease of core body temperature mainly occurred within 75 min after anesthesia induction, which was significantly greater in room body temperature group, and the application of warm irrigation fluid remained the temperature at higher level after then, this result indicated shorter operation time brought smaller temperature change within 75 min, and warm irrigation fluid was more recommendable for those with a longer length of surgery. Although hypothermia is a common perioperative occurrence, it is not a benign one, and the consequences are far more serious than an uncomfortable perception of cold. It may result in shivering, which is defined as an involuntary and repetitive activity of skeletal muscles. In general, shivering can increase oxygen consumption, lactic acidosis, carbon dioxide production, and metabolic rate [29, 30]. Therefore, it may cause a series of problems, especially to those with low cardiac and pulmonary reserves. In our opinion, the mechanism of shivering is mainly the intraoperative heat loss caused by the use of irrigation fluid with a temperature below normal body temperature, A significant higher incidence of postoperative shivering was observed in those with room-temperature irrigation fluid. This outcome was similar with that reported by Kim et al., in which the incidence was 21.7 % in the room temperature fluid group and 0 in the warmed fluid group [9]. In fact, room-temperature irrigation fluid was a local physical stimulus to the body. After the irrigation initiating the drops in core body temperature were obviously. The reactive mechanism is very complicated and the results of different studies are not consistent, which may attribute to the duration and the action mode of cold stimulus. But lots of studies have proved that cold stress could influence the immune responses by elevating the levels of inflammatory cytokines, including pro- and anti-inflammatory cytokines [16, 31, 32]. So the studies of systemic and locally inflammatory and immunologic parameters will provide important information, and it has been demonstrated that serum and local inflammatory cytokines were related to the extent and severity of the surgical procedure [33, 34]. TNF-a, IL-1, IL-6 are well-recognized proinflammatory cytokines and play an important role in the pathogenesis of immune-mediated inflammation. Glaser R et al. found that cold stress could induce the increases of TNF-a and IL-6 levels [15]. Brenner et al. examined the human immune responses to cold exposure and found a rise in serum levels of IL-6 [35]. In the study performed by Guo J R et al., the authors found that cold stress could enhance proinflammatory cytokines (TNF-a, IL-1, IL-6) profile and alterations of Th1 and Th2 type cytokines secretion in the serum of rats [16].
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Production of proinflammatory cytokines such as TNF-a and IL-6 is an accurate marker of the overall acute-phase response, and their serum levels are used to monitor the impact of surgical trauma [36]. In our study, serum IL-6 levels were significantly lower in Group W postoperatively, therefore arthroscopic shoulder surgery with the usage of warmed irrigation fluid was considered less traumatic. Serum TNF-a levels were undetectable, which was consistent with previous studies [34, 37, 38]. This can be explained that TNF receptorsI and II are soluble, which are shed in circulatory system in response to the same stimuli that are known to induce TNF-a [39]. For serum IL1 and IL-10, no significant differences were found between groups, and preoperative and postoperative levels did not differ significantly. In fact, these proinflammatory cytokines are mainly generated locally, and circulating proinflammatory cytokines are mostly derived from the operative area. That is why local levels are much higher than those measured systematically [32]. And serum levels could only represent a small fragment of what is generated in surgical site. Although proinflammatory cytokines in serum was not well characterized after surgical trauma, the differences at the local tissue were enormous. Previous studies also indicated that examination of local cytokines is likely to be of more primary biologic and clinical importance [38]. As known to all, the inflammatory cascade is initiated by the production of TNF-a and IL-1, then followed by IL-6 [38]. These three cytokines are major mediators of the acutephase response in human, and have been accepted as markers of tissue trauma after surgery [40]. For the results of TNF-a, IL-1, and IL-6, significantly lower levels were observed in Group W, which indicated that room temperature as a cold stimulus could enhance the inflammatory response and cause more damage to local tissue. In addition, we also measured the levels of IL-10. As an antiinflammatory cytokine, it could decrease the amount of proinflammatory cytokines and is regard as a key indicator of inflammation. Our result showed that its levels were also markedly elevated in room-temperature irrigation fluid group. Normally, many symptoms caused by inflammatory response could be used to assess its severity, including swelling, reddening, fever, and wound pain. In our study, higher mean postoperative VAS scores were obtained in room temperature fluid irrigation group, which was in accordance with the above results. Even so, some limitations should be mentioned. Although a negative pressure absorbing ball was used in collecting the drainage fluid, the total volume was still relative small and seldom could be drained out after 6 h postoperatively, then the detection of inflammatory cytokines in drainage fluid was only conducted within 6 h and no more data could be provided. Also, we only
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measured the levels of TNF-a, IL-1, IL-6, and IL-10. To confirm our hypothesis and findings, measurements of other inflammatory cytokines may also be helpful. In conclusion, hypothermia occurs more often in arthroscopic shoulder surgery by using room-temperature irrigation fluid compared with warm irrigation fluid. And local inflammatory response, as measured by TNF-a, IL-1, IL-6, and IL-10 responses, is significantly reduced by using warm irrigation fluid. So it seems that warm irrigation fluid is more recommendable for arthroscopic shoulder surgery.
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Arch Orthop Trauma Surg 16. Guo JR, Li SZ, Fang HG et al (2012) Different duration of cold stress enhances pro-inflammatory cytokines profile and alterations of Th1 and Th2 type cytokines secretion in serum of wistar rats. J Anim Vet Adv 11:1538–1545 17. Roberts CS, Pape HC, Jones AL et al (2004) Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect 54:447–462 18. Sears BW, Stover MD, Callaci J (2009) Pathoanatomy and clinical correlates of the immunoinflammatory response following orthopaedic trauma. J Am Acad Orthop Surg 17(4):255–265 19. Pinsky MR, Vincent JL, Devie`re J et al (1993) Serum cytokine levels in human septic shock. Relation to multiple-system organ failure and mortality. Chest J 103(2):565–575 20. Blackwell TS, Christman JW (1996) Sepsis and cytokines: current status. Br J Anaesth 77(1):110–117 21. Lho YM, Ha E, Cho CH et al (2013) Inflammatory cytokines are overexpressed in the subacromial bursa of frozen shoulder. J Shoulder Elbow Surg 22(5):666–672 22. Burger L, Fitzpatrick J (2009) Prevention of inadvertent perioperative hypothermia. Br J Nurs 18(18):1114 23. Torossian A (2008) Thermal management during anaesthesia and thermoregulation standards for the prevention of inadvertent perioperative hypothermia. Best Pract Res Clin Anaesthesiol 22(4):659–668 24. Putzu M, Casati A, Berti M et al (2007) Clinical complications, monitoring and management of perioperative mild hypothermia: anesthesiological features. Acta Biomed 78(3):163–169 25. Zhao Z, Wu C, He M (2012) A systematic review of clinical outcomes, perioperative data and selective adverse events related to mild hypothermia in intracranial aneurysm surgery. Clin Neurol Neurosurg 114(7):827–832 26. Pagnocca ML, Tai EJ, Dwan JL (2009) Temperature control in conventional abdominal surgery: comparison between conductive and the association of conductive and convective warming. Revista brasileira de anestesiologia 59(1):56–66 27. Duff J, Di Staso R, Cobbe KA et al (2012) Preventing hypothermia in elective arthroscopic shoulder surgery patients: a protocol for a randomised controlled trial. BMC Surg 12(1):14 28. Oh JH, Kim JY, Chung SW et al (2014) Warmed irrigation fluid does not decrease perioperative hypothermia during arthroscopic shoulder surgery. Arthroscopy 30(2):159–164
29. Tsai YC, Chu KS (2001) A comparison of tramadol, amitriptyline, and meperidine for postepidural anesthetic shivering in parturients. Anesth Analg 93(5):1288–1292 30. Macintyre PE, Pavlin EG, Dwersteg JF (1987) Effect of meperidine on oxygen consumption, carbon dioxide production, and respiratory gas exchange in postanesthesia shivering. Anesth Analg 66(8):751–755 31. Rybakina EG, Shanin SN, Kozinets IA et al (1996) Cellular mechanisms of cold stress-related immunosuppression and the action of interleukin 1. Int J Tissue React 19(3–4):135–140 32. Cichon´ M, Chadzin´ska M, Ksia˛z_ ek A et al (2002) Delayed effects of cold stress on immune response in laboratory mice. Proc R Soc Lond B Biol Sci 269(1499):1493–1497 33. Lin E, Calvano SE, Lowry SF (2000) Inflammatory cytokines and cell response in surgery. Surgery 127(2):117–126 34. Wu FPK, Sietses C, Von Blomberg BME et al (2003) Systemic and peritoneal inflammatory response after laparoscopic or conventional colon resection in cancer patients. Dis Colon Rectum 46(2):147–155 35. Brenner IKM, Castellani JW, Gabaree C et al (1999) Immune changes in humans during cold exposure: effects of prior heating and exercise. J Appl Physiol 87(2):699–710 36. Gabay C, Kushner I (1999) Acute-phase proteins and other systemic responses to inflammation. N Engl J Med 340(6):448–454 37. Tokunaga A, Onda M, Fujita I et al (1993) Sequential changes in the cell mediators of peritoneal and wound fluids after surgery. Surg Today 23(9):841–844 38. Wiik H, Karttunen R, Haukipuro K et al (2001) Maximal local and minimal systemic cytokine response to colorectal surgery: the influence of perioperative filgrastim. Cytokine 14(3):188–192 39. Van Zee KJ, Kohno T, Fischer E et al (1992) Tumor necrosis factor soluble receptors circulate during experimental and clinical inflammation and can protect against excessive tumor necrosis factor alpha in vitro and in vivo. Proc Natl Acad Sci 89(11):4845–4849 40. Leung KL, Lai PBS, Ho RLK et al (2000) Systemic cytokine response after laparoscopic-assisted resection of rectosigmoid carcinoma: a prospective randomized trial. Ann Surg 231(4):506
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ARTHROSCOPY AND SPORTS MEDICINE
Effect of irrigation fluid temperature on core body temperature and inflammatory response during arthroscopic shoulder surgery Xiaoyun Pan1 • Luyou Ye1 • Zhongtang Liu2 • Hong Wen1 • Yuezheng Hu1 Xinxian Xu1
•
Received: 14 February 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose This study was designed to evaluate the influence of irrigation fluid on the patients’ physiological response to arthroscopic shoulder surgery. Methods Patients who were scheduled for arthroscopic shoulder surgery were prospectively included in this study. They were randomly assigned to receive warm arthroscopic irrigation fluid (Group W, n = 33) or room temperature irrigation fluid (Group RT, n = 33) intraoperatively. Core body temperature was measured at regular intervals. The proinflammatory cytokines TNF-a, IL-1, IL-6, and IL-10 were measured in drainage fluid and serum. Results The changes of core body temperatures in Group RT were similar with those in Group W within 15 min after induction of anesthesia, but the decreases in Group RT were significantly greater after then. The lowest temperature was 35.1 ± 0.4 °C in Group RT and 35.9 ± 0.3 °C in Group W, the difference was statistically different (P \ 0.05). Hypothermia occurred in 31 out of 33 subjects in Group RT (31/33; 94 %), but was significantly lower in Group W (9/24; 27 %; P \ 0.05). Serum TNF-a changes were undetectable postoperatively. No statistical significant differences in serum IL-1 and serum IL-10 levels were observed between groups. Serum IL-6 levels were significantly lower in Group W (P \ 0.05). The levels
X. Pan and L. Ye have contributed equally to this study. & Xinxian Xu [email protected] 1
The Osteopathy Department, The Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
2
The Osteopathy Department, The Changhai Hospital, Second Military Medical University, Shanghai, China
of the above cytokines in drainage fluid were all significantly lower in Group W after surgery (P \ 0.05). Conclusion Hypothermia occurs more often in arthroscopic shoulder surgery by using room temperature irrigation fluid compared with warm irrigation fluid. And local inflammatory response is significantly reduced by using warm irrigation fluid. It seems that warm irrigation fluid is more recommendable for arthroscopic shoulder surgery. Keywords Arthroscopic Shoulder surgery Hypothermia Proinflammatory cytokines
Introduction Arthroscopic technology is widely used in clinical diagnosis and treatment of shoulder disorders. In this type of surgery, large volumes of irrigation fluid are used to dilate the operating field and usually maintained at room temperature. Because the shoulder is not a closed anatomical space and located close to the core body structure, a lot of fluid will leak out and reach the chest, which may lead to a vast temperature variation [8, 9]. Then core temperature will drop and hypothermia may appear. Perioperative hypothermia, defined as core temperature less than 36 °C, is a common occurrence during the surgery. Many factors, such as low ambient temperature, long length of anesthesia, massive blood loss, and excess intravenous fluid, could increase the incidence [1]. It should be avoided whenever possible as numerous complications may arise, including increased risk of postoperative cardiovascular accident [2], increased risk of wound infection [3], prolonged duration of anesthesia recovery [4], increased incidence of postoperative shivering [5], and coagulopathy [6], so timely interventions are necessary. To
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date, to decrease the incidence of hypothermia during arthroscopic shoulder surgery, many protocols have been created [7], among which the application of warmed irrigation fluid is a good choice. Several published reports supported that warm irritation fluid (36 °C) is an efficient measure in reducing the occurrence of perioperative hypothermia during arthroscopic shoulder surgery [8, 9]. Surgery is a controlled trauma with immunologic consequences [10]. Compared with warm irrigation fluid, room-temperature irrigation fluid is a local physical stimulus to the body [11]. As an acute stressor, it may have its unique characteristic of neuroendocrine changes because the accompanying temperature variations may affect immune system. Inflammatory cytokines, which mainly produced at the trauma site, plays an important role in eliciting this systemic stress response [12]. As a heterogeneous group of soluble short-acting glucoproteins, inflammatory cytokines are released by cells of immune system and involved in the regulation of immune and inflammatory response [13, 14]. Normally, the absolute amounts of cytokine production are very low, which limits their actions to the local tissues. However, under stress conditions, excessive amounts would be released and could overspill into the systemic circulation rapidly. It has been reported that many proinflammatory cytokines, such as TNF-a, IL-1, IL-6, significantly increased under cold stress [15, 16]. And this production could induce the up-regulation of anti-inflammatory cytokines, such as IL-4 and IL-10, which could decrease the severity of inflammatory response [17, 18]. This inflammatory response is proportional to the severity of surgical trauma. It was reported that this sequence of steps was associated with multiple organ-system dysfunction and mortality postoperatively [19, 20]. For local structure like shoulder and knee joint, this response is concerned with regional pain and joint effusion [21]. Despite this, there is still no study on the relationship between the temperature of irrigation fluid and the levels of inflammatory cytokines during arthroscopic shoulder surgery. We therefore conducted this study to determine whether the core body temperature and the levels of perioperative inflammatory cytokines were changed with different temperatures of irrigation fluid. Our hypothesis was that warm irrigation fluid during arthroscopic shoulder surgery can decrease perioperative hypothermia and inflammatory response.
Patients and methods Study design Between November 2012 and May 2013, we conducted this randomized, open-label, controlled clinical study at our
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department. Patients who were scheduled for arthroscopic shoulder surgery were prospectively included in this study. They were randomly assigned to receive warm irrigation fluid or room-temperature irrigation fluid during the surgery. Core body temperature was measured perioperatively. Inflammatory cytokines in drainage fluid and serum were measured postoperatively. And adverse events were recorded. This protocol was approved by the Institutional Review Board of Wenzhou Medical University before initiating. It was conducted in accordance with the Helsinki Declaration and in compliance with the Good Clinical Practice Guidelines. Each participant gave informed written consent before entry into this study. Patients Of 86 eligible patients, 8 were excluded because of incomplete data. The remaining 78 between 27- and 73-year old were available for further tracking study. All of them were free of severe chronic medical diseases or chronic disabling diseases that could not tolerate surgical management. We also excluded patients with massive rotator cuff tears or previous operations on the same shoulder, as well as those require external warming devices before or during surgery. Finally, 66 subjects met all of the eligibility criteria and were randomly allocated to receive warm irrigation fluid (Group W, n = 33) or room-temperature irrigation fluid (Group RT, n = 33) by using a random number table generated by computer. Preoperative preparation The temperature of the operating room was automatically maintained at 21 °C. All intravenous fluids were administered at room temperature and given without inline warming. All patients were covered with two layers of surgical drapes during the surgery and one cotton blanket over the entire body postoperatively. In our study, normal saline in a 3-L bag without any other additional agent was used as the irrigation fluid. The patients in Group RT received irrigation fluid maintained at 21 °C, and those in Group W received the fluid with a temperature of 36 °C. All irrigation fluid was pre-warmed and kept by using the same electrical heating tank (Fuyilian, Beijing, China), and was delivered with a pressurecontrolled pump set to 60 mmHg. In additional, all normal saline bags were put into a Styrofoam box, and a digital thermometer was placed for real-time temperature monitoring at the same time. Vital signs, including pulse, blood pressure, and respiratory rate were monitored continuously throughout the operation. General anesthesia was required for all patients
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and all procedures were completed by the same senior anesthesiologist. After induction of general anesthesia, an esophageal temperature probe (Mon-a-therm, TycoMallinckrodt Anesthesiology Products, St. Louis, MO) was inserted to monitor the core body temperature, which was recorded at 15-min intervals during the operation.
TNF-a, IL-1, IL-6, and IL-10 levels in drainage fluid and serum were measured using ELISA kits from Bio-Tech (Shanghai, China), according to the manufacturer,s instructions.
Surgical procedures
All statistical tests for related measurement and count data were two-sided and evaluated at a 5 % level of significance. The statistical significance of differences of continuous data such as core temperature score, VAS score, and level of inflammatory cytokines was assessed by using an independent t test. And dichotomous variables such as the incidences of hypothermia, shivering, and AE were compared by use of Chi-square test or Fisher exact test. All statistical analyses were performed with SPSS software (Version 19.0; SPSS, Chicago, IL).
All the arthroscopic surgeries were performed by the same senior surgeon. Following induction of general anesthesia, the patient was placed in the lateral decubitis position. Except 12 cases of flat type of acromion checked on preoperative radiograph, subacromial decompression with acromioplasty was performed in 54 cases. Biceps tenotomy was performed in 27 cases, including 16 with a symptomatic biceps tear greater than 50 % and 11 with unstable biceps. After adequate visualization, preparation, and exposure, the torn cuffs were repaired by using singleor double-row technology according to tear size and degeneration grade. Finally, a standard polyvinyl chloride suction drain with an external of 2 mm was placed into the shoulder joint from the lateral portal. Then the drain was tied and a negative pressure absorbing ball was connected. Data collection After operation, all patients were sent to PACU for further assessment. The room temperature was still maintained at 21 °C, and core body temperature was measured at 15-min intervals for 1 hour. Other crucial indicators, including length of anesthesia, length of surgery, amount of intravenous fluid, and amount of irrigation fluid were all recorded. Adverse events (AEs), such as postoperative shivering, vomiting, headache, and cardiovascular events were also closely monitored. Blood hemoglobin level, weight, and pain measure with visual analog scale (VAS) were rechecked on the first day postoperatively. Detection of inflammatory cytokines At hours 0, 3, and 6 postoperatively, the drainage fluid from the suction drain was obtained with the help of an abacterial syringe. All samples were put on ice and taken to the laboratory promptly, where they were firstly centrifuged at 15009g, for 15 min at 4 °C. Then the supernatants were isolated and centrifuged again at 30009g for next 15 min. After twice centrifugation, the final supernatants were aliquoted and frozen at -80 °C before further analyses. Meanwhile, whole blood was drawn at 6, 12, and 24 h after surgery. Serum was obtained from the whole blood and also stored at -80 °C.
Statistical method
Results All data were gathered and analyzed by the same statistician. The baseline demographic characteristics and clinical data are shown in Table 1. Age distribution was an average of 48.0 years and BMI was 25.2 kg/m2. No significant differences in initial core body temperature, preoperative VAS score, and preoperative hemoglobin level were observed, as well as in total intravenous fluid, total irrigation fluid, and mean irrigation fluid perioperatively. The length of surgery, ranged from 61 to 149 min, was 92.1 ± 21.2 min in Group RT, which was not significantly different from that in Group W (93.8 ± 25.9; P [ 0.05). The length of anesthesia in Group RT and Group W were 142.8 ± 20.1 and 145.6 ± 26.2 min, respectively, which was also not significant (P [ 0.05). The performances of arthroscopic procedures were similar between the two groups. Specifically, 30 (91 %) subjects in Group RT and 24 (72 %) in Group W received acromioplasty, 12 (36 %) in Group RT and 15 (46 %) in Group W received biceps tenotomy, and 14 (42 %) in Group RT and 11 (33 %) in Group W received double-row rotator cuff repair. The core body temperatures of both groups had clear and early decreases after anesthesia induction, which went down linearly within 75 min and stayed stable in the following period. And both increased gradually in recovery stage (Fig. 1). The changes in Group RT were similar with those in Group W within 15 min, but significantly greater after then, which penetrated the following period and persisted throughout 1 h after anesthesia. The lowest temperature, which was obtained in 90 min during anesthesia, was 35.1 ± 0.4 °C in Group RT and 35.9 ± 0.3 °C in Group W. Their difference was statistically different
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Arch Orthop Trauma Surg Table 1 Demographic characteristics and clinical data Age (year)
Group RT (n = 33)
Group W (n = 33)
49.2 ± 11.8
47.6 ± 10.3
Gender
0.554 0.612
Male
11
Female
22
19
24.7 ± 3.2
25.7 ± 3.1
Body mass index (BMI) (kg/m2)
P
14 0.209
Initial core body temperature (°C)
36.6 ± 0.3
36.5 ± 0.3
0.668
Preoperative VAS score
6.8 ± 1.4
7.1 ± 1.2
0.312 0.820
Preoperative hemoglobin level (g/dl)
14.0 ± 1.2
14.1 ± 0.9
Length of surgery (min)
92.1 ± 21.2
93.8 ± 25.9
0.780
Length of anesthesia (min)
142.8 ± 20.1
145.6 ± 26.2
0.626
Total intravenous fluid (ml)
607.6 ± 269.3
620.6 ± 265.1
0.844
Total irrigation fluid (L)
11.2 ± 2.9
11.6 ± 3.3
0.669
Mean irrigation fluid (L/h)
7.2 ± 0.5
7.4 ± 04
0.178
Operating room temperature (°C)
20.8 ± 0.5
21.0 ± 0.6
0.154
Arthroscopic procedures Acromioplasty
0.108
Yes
30
24
No
3
9
Yes
12
15
No
21
18
Single row
19
22
Double row
14
11
Biceps tenotomy
0.617
Rotator cuff repair
0.612
Fig. 1 Changes of core temperature during the operations in Group RT and Group W. *P \ 0.05, Group RT vs. Group W (OR, operation room)
(P \ 0.05). Hypothermia was observed in both groups (Table 2). It occurred in 31 out of 33 subjects in Group RT (31/33; 94 %), whereas this marker was much lower in Group W (9/24; 27 %; P \ 0.05). All drainage tubes were removed at 24 h postoperatively and the amount of drainage fluid was recorded. The total volume was 11.3 ± 4.4 ml in Group RT and 10.8 ± 4.2 ml in Group W, there was no significant difference between them (P [ 0.05) (Table 2). In addition, no
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intergroup differences were noted in hemoglobin decreases and VAS scores at 6 h and 3 days postoperatively (Table 2). The inflammatory cytokines in serum were measured at 6 h preoperatively and 6, 12, and 24 h postoperatively. In addition, local production of these indicators was evaluated in drainage fluid at 0, 2, 6 h after surgery. Tables 3 and 4 summarize serum and drainage fluid levels of TNF-a, IL-1, IL-6, and IL-10. TNF-a levels were undetectable in serum,
Arch Orthop Trauma Surg Table 2 Clinical Data perioperatively
Group RT (n = 33)
Group W (n = 33)
Yes
31 (0.94)
9 (0.27)
No
2
24
11.3 ± 4.4
10.8 ± 4.2
Hypothermia
Total drainage fluid (ml)
P 0.000*
0.619
Hemoglobin decrease (g/dl) 6 h postoperatively
1.3 ± 0.9
1.5 ± 0.7
0.355
3 days postoperatively
0.1 ± 0.6
0.2 ± 0.6
0.403
VAS score 6 h postoperatively
4.0 ± 1.1
4.6 ± 1.4
0.087
3 days postoperatively
3.1 ± 1.3
3.2 ± 1.2
0.842
AEs Shivering, [n (%)]
14 (42)
1 (3)
0.000*
Vomiting, [n (%)]
0 (0)
1 (3)
1.000
Nausea, [n (%)]
3 (9)
1 (3)
0.613
Dizziness, [n (%)] Headache, [n (%)]
8 (24) 3 (9)
5 (15) 2 (6)
0.537 1.000
but were measurable in drainage fluid. As shown in Fig. 2, continuing increases in local production could be observed in both groups from 0 to 6 h postoperatively, and the levels in Group RT were significantly higher (P \ 0.05). Serum IL-1 levels did not differ between the two groups at any time (P [ 0.05). Drainage fluid IL-1 levels are depicted in Fig. 3. Similar to TNF-a, IL-1 levels increased continuously from 0 to 6 h postoperatively, and the levels of this indictor were significantly lower in Group W after surgery (P \ 0.05). Serum and drainage fluid IL-6 levels are described in Figs. 4 and 5. In both groups, the serum levels are highest at 6 h and downward trends could be observed after this point, and the differences between preoperative and postoperative levels were all significant (P \ 0.05). There was no significant difference between
groups preoperatively (P [ 0.05). However, after surgery, the levels in Group RT were all significantly higher (P \ 0.05). Continuing increases in drainage fluid could be observed in both groups, and also significant higher levels were observed in Group RT (P \ 0.05). For IL-10, its changes were similar to IL-1. Specially, no significant changes between groups and between preoperative and postoperative levels in serum were observed (P [ 0.05). For their drainage fluid levels described in Fig. 6, though no statistical difference was observed at 0 h (P [ 0.05), they were significantly lower in Group W at 2 and 6 h (P \ 0.05). Higher mean postoperative VAS scores were obtained in room temperature fluid irrigation group 6 h postoperatively. Shivering was observed in 14 patients in Group
Table 3 The inflammatory cytokines levels in serum Preoperative (pg/ml)
6 h postoperatively (pg/ml)
12 h postoperatively (pg/ml)
24 h postoperatively (pg/ml)
Group W
0
0
0
0
Group RT
0
0
0
0
5.6 ± 2.3 6.8 ± 3.1
6.0 ± 2.5 6.3 ± 2.8
5.1 ± 2.9 6.2 ± 3.3
5.9 ± 3.3 5.8 ± 2.9
TNF-a
IL-1 Group W Group RT IL-6 Group W
19.2 ± 8.3*
109.9 ± 23.4*
95.3 ± 21.6*
73.5 ± 24.0*
Group RT
17.2 ± 7.1
137.2 ± 30.7
130.6 ± 24.9
93.3 ± 24.9
IL-10 Group W
3.6 ± 2.0
4.3 ± 2.6
5.1 ± 2.4
4.3 ± 2.4
Group RT
2.8 ± 1.7
4.9 ± 2.9
5.6 ± 2.1
4.4 ± 2.6
* P \ 0.05, Group W vs. Group RT
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Arch Orthop Trauma Surg Table 4 The inflammatory cytokines levels in drainage fluid
0 h postoperatively (pg/ml)
2 h postoperatively (pg/ml)
6 h postoperatively (pg/ml)
TNF-a Group W
74.2 ± 18.4*
Group RT
93.0 ± 23.8
114.1 ± 21.8
95.8 ± 18.1*
139.6 ± 24.0
101.5 ± 21.7*
Group W
119.3 ± 32.0*
169.9 ± 34.6*
180.8 ± 46.1*
Group C
141.1 ± 39.7
194.7 ± 44.3
212.2 ± 34.6
IL-1
IL-6 Group W
6543.6 ± 1333.2*
Group C
7817.0 ± 1645.8
9960.0 ± 1225.2* 11,504.2 ± 1590.4
10,161.2 ± 1268.2* 11,890.4 ± 1574.8
IL-10 Group W
196.0 ± 56.2
367.0 ± 58.1*
450.5 ± 53.8*
Group C
210.7 ± 63.6
448.9 ± 58.2
515.7 ± 63.4
* P \ 0.05, Group W vs. Group RT
Fig. 2 TNF-alevels in drainage fluid, mean ± standard error of the mean. *P \ 0.05, Group W vs. Group RT
Fig. 4 IL-6 levels in serum, mean ± standard error of the mean. *P \ 0.05, Group W vs. Group RT. #P \ 0.05, postoperative values vs. perioperative values
Fig. 3 IL-1 levels in drainage fluid, mean ± standard error of the mean. *P \ 0.05, Group W vs. Group RT
Fig. 5 IL-6 levels in drainage fluid, mean ± standard error of the mean. *P \ 0.05, Group W vs. Group RT
RT (14/33, 42 %) at recovery stage, but only 1 patient experienced shivering in Group W (1/33; 3%; P \ 0.05). A total of 14 (42 %) patients reported at least one AE except
for Shivering, but no serious AE such as heart failure or cerebrovascular accident occurred. The proportions did not differ according to treatment group (P [ 0.05).
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Fig. 6 IL-10 levels in drainage fluid, mean ± standard error of the mean. *P \ 0.05, Group W vs. Group RT
Discussion Perioperative hypothermia is a common symptom during anesthesia and surgery [22]. Mild hypothermia may be beneficial, as it can reduce metabolic rate and oxygen consumption, and increase tolerance of organs and tissues to hypoxia and ischemia [24, 25]. But a long lasting or severe one should be avoided because its potential complications could adversely influence the surgical effectiveness [23, 24, 26]. As large volumes of roomtemperature irrigation fluid are used, patients undergoing arthroscopic shoulder surgery are particularly prone to hypothermia [27]. However, there are few studies that focus on this tissue and conflicting opinions are worth mentioning. Board T N et al. carried out a clinical study on 24 patients undergoing arthroscopic subacromial decompression. In their study, the patients received room temperature (22 °C) or warmed (36 °C) irrigation fluid during the surgery. The authors found that the incidence of hypothermia was significantly higher when using room temperature fluid, and concluded that core temperature may be influenced by irrigation fluid temperature [8]. In another study performed by Kim et al., 50 cases undergoing arthroscopic shoulder surgery were randomly allocated to receive either room temperature or warmed irrigation fluid (37–39 °C). During the surgery, the mean maximum drop in the room temperature fluid group and the warmed fluid group was 0.86 ± 0.2 and 0.28 ± 0.2 °C, respectively (P \ 0.001). They concluded that hypothermia occurred more often with room-temperature irrigation fluid [9]. But on the contrary, Joo Han et al. showed that irrigation fluid temperature was not a factor responsible for altering the core body temperature in this type of surgery [28]. In our study, we found that large volumes of room-temperature irrigation fluid could cause significant drops in core body temperature during arthroscopic shoulder surgery, while warm irrigation fluid could markedly reduce the drops,
which was similar with the outcomes reported by Board T N and Kim et al. [8, 9]. What was more, in both groups, the decrease of core body temperature mainly occurred within 75 min after anesthesia induction, which was significantly greater in room body temperature group, and the application of warm irrigation fluid remained the temperature at higher level after then, this result indicated shorter operation time brought smaller temperature change within 75 min, and warm irrigation fluid was more recommendable for those with a longer length of surgery. Although hypothermia is a common perioperative occurrence, it is not a benign one, and the consequences are far more serious than an uncomfortable perception of cold. It may result in shivering, which is defined as an involuntary and repetitive activity of skeletal muscles. In general, shivering can increase oxygen consumption, lactic acidosis, carbon dioxide production, and metabolic rate [29, 30]. Therefore, it may cause a series of problems, especially to those with low cardiac and pulmonary reserves. In our opinion, the mechanism of shivering is mainly the intraoperative heat loss caused by the use of irrigation fluid with a temperature below normal body temperature, A significant higher incidence of postoperative shivering was observed in those with room-temperature irrigation fluid. This outcome was similar with that reported by Kim et al., in which the incidence was 21.7 % in the room temperature fluid group and 0 in the warmed fluid group [9]. In fact, room-temperature irrigation fluid was a local physical stimulus to the body. After the irrigation initiating the drops in core body temperature were obviously. The reactive mechanism is very complicated and the results of different studies are not consistent, which may attribute to the duration and the action mode of cold stimulus. But lots of studies have proved that cold stress could influence the immune responses by elevating the levels of inflammatory cytokines, including pro- and anti-inflammatory cytokines [16, 31, 32]. So the studies of systemic and locally inflammatory and immunologic parameters will provide important information, and it has been demonstrated that serum and local inflammatory cytokines were related to the extent and severity of the surgical procedure [33, 34]. TNF-a, IL-1, IL-6 are well-recognized proinflammatory cytokines and play an important role in the pathogenesis of immune-mediated inflammation. Glaser R et al. found that cold stress could induce the increases of TNF-a and IL-6 levels [15]. Brenner et al. examined the human immune responses to cold exposure and found a rise in serum levels of IL-6 [35]. In the study performed by Guo J R et al., the authors found that cold stress could enhance proinflammatory cytokines (TNF-a, IL-1, IL-6) profile and alterations of Th1 and Th2 type cytokines secretion in the serum of rats [16].
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Production of proinflammatory cytokines such as TNF-a and IL-6 is an accurate marker of the overall acute-phase response, and their serum levels are used to monitor the impact of surgical trauma [36]. In our study, serum IL-6 levels were significantly lower in Group W postoperatively, therefore arthroscopic shoulder surgery with the usage of warmed irrigation fluid was considered less traumatic. Serum TNF-a levels were undetectable, which was consistent with previous studies [34, 37, 38]. This can be explained that TNF receptorsI and II are soluble, which are shed in circulatory system in response to the same stimuli that are known to induce TNF-a [39]. For serum IL1 and IL-10, no significant differences were found between groups, and preoperative and postoperative levels did not differ significantly. In fact, these proinflammatory cytokines are mainly generated locally, and circulating proinflammatory cytokines are mostly derived from the operative area. That is why local levels are much higher than those measured systematically [32]. And serum levels could only represent a small fragment of what is generated in surgical site. Although proinflammatory cytokines in serum was not well characterized after surgical trauma, the differences at the local tissue were enormous. Previous studies also indicated that examination of local cytokines is likely to be of more primary biologic and clinical importance [38]. As known to all, the inflammatory cascade is initiated by the production of TNF-a and IL-1, then followed by IL-6 [38]. These three cytokines are major mediators of the acutephase response in human, and have been accepted as markers of tissue trauma after surgery [40]. For the results of TNF-a, IL-1, and IL-6, significantly lower levels were observed in Group W, which indicated that room temperature as a cold stimulus could enhance the inflammatory response and cause more damage to local tissue. In addition, we also measured the levels of IL-10. As an antiinflammatory cytokine, it could decrease the amount of proinflammatory cytokines and is regard as a key indicator of inflammation. Our result showed that its levels were also markedly elevated in room-temperature irrigation fluid group. Normally, many symptoms caused by inflammatory response could be used to assess its severity, including swelling, reddening, fever, and wound pain. In our study, higher mean postoperative VAS scores were obtained in room temperature fluid irrigation group, which was in accordance with the above results. Even so, some limitations should be mentioned. Although a negative pressure absorbing ball was used in collecting the drainage fluid, the total volume was still relative small and seldom could be drained out after 6 h postoperatively, then the detection of inflammatory cytokines in drainage fluid was only conducted within 6 h and no more data could be provided. Also, we only
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measured the levels of TNF-a, IL-1, IL-6, and IL-10. To confirm our hypothesis and findings, measurements of other inflammatory cytokines may also be helpful. In conclusion, hypothermia occurs more often in arthroscopic shoulder surgery by using room-temperature irrigation fluid compared with warm irrigation fluid. And local inflammatory response, as measured by TNF-a, IL-1, IL-6, and IL-10 responses, is significantly reduced by using warm irrigation fluid. So it seems that warm irrigation fluid is more recommendable for arthroscopic shoulder surgery.
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