Korean J Anesthesiol.  2006 Feb;50(2):217-220. 10.4097/kjae.2006.50.2.217.

Hypothermia Induced by Incorrect Monitoring of Core Temperature: A case report

• Bahn YJ
• Shin HW
• Lee HW
• Lim HJ
• Yoon SM
• Chang SH

• KMID: 2237463
• DOI: http://doi.org/10.4097/kjae.2006.50.2.217

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.

Keyword

hypothermia; temperature monitoring; temporal-artery thermometer

MeSH Terms

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
Cardiovascular Agents