57291986

REVIEW

A systematic review of randomised controlled trials of the effects of

warmed irrigation fluid on core body temperature during endoscopic

surgeries

Yinghui Jin, Jinhui Tian, Mei Sun and Kehu Yang

Aims and objectives. The purpose of this systematic review was to establish whether warmed irrigation fluid temperature could

decrease the drop of body temperature and incidence of shivering and hypothermia.

Background. Irrigation fluid, which is used in large quantities during endoscopic surgeries at room temperature, is considered to

be associated with hypothermia and shivering. It remains controversial whether using warmed irrigation fluid to replace room-

temperature irrigation fluid will decrease the drop of core body temperature and the occurrence of hypothermia.

Design. A comprehensive search (computerised database searches, footnote chasing, citation chasing) was undertaken to

identify all the randomised controlled trials that explored temperature of irrigation fluid in endoscopic surgery. An approach

involving meta-analysis was used.

Method. We searched PubMed, EMBASE, Cochrane Library, SCI, China academic journals full-text databases, Chinese Bio-

medical Literature Database, Chinese scientific journals databases and Chinese Medical Association Journals for trials that meet

the inclusion criteria. Study quality was assessed using standards recommended by Cochrane Library Handbook 5.0.1. Dis-

agreement was resolved by consensus.

Results. Thirteen randomised controlled trials including 686 patients were identified. The results showed that room-tempera-

ture irrigation fluid caused a greater drop of core body temperature in patients, compared to warmed irrigation fluid

(p < 0Æ00001; I2 = 85%). The occurrence of shivering [odds ratio (OR) 5Æ13, 95% CI: 2Æ95–10Æ19, p < 0Æ00001; I2 = 0%] and

hypothermia (OR 22Æ01, 95% CI: 2Æ03–197Æ08, p = 0Æ01; I2 = 64%) in the groups having warmed irrigation fluid were lower

than the group of studies having room-temperature fluid.

Conclusions. In endoscopic surgeries, irrigation fluid is recommended to be warmed to decrease the drop of core body tem-

perature and the risk of perioperative shivering and hypothermia.

Relevance to clinical practice. Warming irrigating fluid should be considered standard practice in all endoscopic surgeries.

Key words: endoscopic surgery, irrigation fluid, systematic review, temperature

Accepted for publication: 31 July 2010

Authors: Yinghui Jin, RN, Nurse, The Evidence-Based Medicine

Center, School of Basic Medical Sciences, Lanzhou University,

Lanzhou and Nursing Department, Tianjin Medical University,

Tianjin; Jinhui Tian, MD, Lecturer, The Evidence-Based Medicine


Lanzhou; Mei Sun, RN, Professor, The Evidence-Based Medicine


Lanzhou and Nursing Department, General Hospital of Tianjin

Medical University, Tianjin; Kehu Yang, MD, Professor, The

Evidence-Based Medicine Center, School of Basic Medical Sciences,

Lanzhou University, Lanzhou and The First Clinical College,

Lanzhou University, Lanzhou, China

Correspondence: Kehu Yang, Evidence-Based Medical Center of

Lanzhou University, No. 199 Dong Gang West Road, Chengguan

District, Lanzhou, Gansu, China. Telephone: +086 13893117077.

E-mail: [email protected]

� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 305–316 305

doi: 10.1111/j.1365-2702.2010.03484.x

Introduction

Inadvertent perioperative hypothermia, defined as core body

temperature £36Æ0 �C, is a common complication induced by

anaesthesia (Harper et al. 2008, p. 293). Torossian (2008,

p. 659) indicates that major adverse outcomes from hypo-

thermia start at 36 �C. Several prospective, randomised trials

have demonstrated several perioperative hypothermia-

induced complications, mainly including: (1) increased the

incidence of postoperative adverse myocardial events (Frank

et al. 1997, p. 1130); (2) increased the incidence of surgical

wound infection (Kurz et al. 1996, p. 1212); (3) prolonged

duration of postanaesthetic recovery (Lenhardt et al. 1997,

p. 1320); (4) increased thermal discomfort (Kurz et al. 1995,

p. 363); (5) induced postoperative shivering which increases

oxygen consumption (Just et al. 1992, p. 63) and (6)

interference with the normal function of the clotting cascade

and reduced ability of platelets (Michelson et al. 1994,

p. 636) leading to intraoperative blood loss (Winkler et al.

2000, p. 981).

The development of perioperative hypothermia is a com-

mon, serious and often troublesome reality faced by anaes-

thetists and perianaesthesia nurses. Factors contributing to

hypothermia include low ambient temperature, length of

anaesthesia and type of surgical procedure. Nowadays,

endoscopic techniques are widely used in clinical diagnosis

and medical treatment. In some endoscopic surgery, large

quantities of irrigation fluid are used at room temperature to

dilate the vision space or operating field and to clear blood

and cut tissue. Several randomised controlled trials have

attributed the drop in core body temperature or perioperative

hypothermia to the use of room-temperature irrigation fluid.

Zaffagnini et al. also found that the use of room-temperature

irrigation solution and the length of the surgical procedure

were associated with a significant reduction in keen-joint

temperature after arthroscopic surgical procedures. Absorp-

tion of irrigating fluid and associated haemodynamic changes

played a role in the development of hypothermia. As blood

circulating through the site of surgery is exposed to tissues

that have been significantly cooled by large volumes of room-

temperature irrigation and heat transfer from the blood to

this site of surgery could lead to cooled blood being returned

to the central circulation so causing a decrease in patient core

body temperature (Zaffagnini et al. 1996, p. 199–200).

Because of the risks associated with hypothermia, active

warming procedures are necessary to maintain normothermia

in all patients undergoing anaesthesia or operation. Never-

theless, the status quo is not satisfactory. A survey performed

in 801 European hospitals showed that temperature moni-

toring was performed in only 19Æ4% of the patients and only

38Æ5% of the patients were actively warmed (Torossian 2007,

p. 668).

Interventions to maintain patient body temperature in the

operation room include covering the patient’s head and body,

increasing ambient room temperature, warming intravenous

and irrigating solutions and applying external warming

devices. Among these methods, forced-air warming and

circulating warm water garment have been proven to be

effective and, when given in large amounts, warmed intra-

venous fluid (Torossian 2008, p. 664). Nevertheless, the

optimal irrigation fluid temperature to be used during some

endoscopic surgeries has been a source of controversy in

published studies.

The question is whether warm irrigating fluid, compared

with room-temperature irrigation fluid, could prevent the

occurrence of perioperative hypothermia during endoscopic

operations. Many published reports have supported the

finding of perioperative hypothermia associated with the

use of room-temperature irrigation fluid and the use of

warmed irrigation fluid to prevent the occurrence of peri-

operative hypothermia. However, Kelly et al. (2000, p. 249)

showed that there was no statistically significant difference in

mean percent temperature decrease between the group

receiving room-temperature fluids and the group receiving

warmed irrigation fluid among patients undergoing knee

arthroscopy and, moreover, the group receiving warmed

irrigation solution tended to have a greater temperature drop

than the control group. Jaffe et al. (2001, p. 1079) reported

the temperature of irrigation fluid is not a factor responsible

for altering the core body temperature in patients undergoing

transurethral resection of the prostate (TURP). Clearly, there

are conflicting views about whether irrigation fluid temper-

ature has an influence on the core body temperature. In

addition, there is another important issue. The view held by

conventional surgery is that the higher the temperature, the

greater the increase in blood loss. Walton and Rawstron

(1981, p. 258) reported that using relatively cooled irrigation

fluid resulted in a small non-statistically significant reduction

in blood loss. Conversely, several studies showed warm

irrigating fluid did not increase blood loss compared to room-

temperature irrigation fluid during TURP or transurethral

resection of bladder tumour (TURBT) (Heathcote & Dyer

1986, p. 670, Zeng et al. 2008, p. 9, Ding et al. 2009, p. 12,

Xie et al. 2009, p. 58). Therefore, in this systematic review,

the researchers sought to identify the effect of warmed

irrigation fluid on body temperature and considered whether

warmed irrigation fluid increase blood loss, compared with

room-temperature irrigation fluid.

Y Jin et al.

306 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 305–316

Materials and methods

Search strategy

The search for relevant literature used several computerised

databases, citation searching and ‘footnote chasing’. We

searched the following databases from inception to June

2009: PubMed, EMBASE, Cochrane Library, SCI, China

academic Journals Full-text Databases, Chinese Biomedical

Literature Database, Chinese Scientific Journals Databases

and Chinese Medical Association Journals using the follow-

ing search terms: ‘(endoscope* OR angioscope* OR arthro-

scope* OR bronchoscope* OR colposcope* OR culdoscope*

OR cystoscope* OR fetoscope* OR embryoscope* OR

hysteroscope* OR laparoscope* OR laryngoscope* OR

mediastinoscope* OR neuroendoscope* OR thoracoscope*

OR ureteroscope*)’ AND ‘(irrigation fluid* OR irrigating

fluid* OR irrigant fluid* OR irrigation solution* OR

irrigating solution* OR irrigant solution*)’ AND ‘(temper-

ature*)’. The search strategy incorporated MeSH terms with

text words search. The detailed search strategy for each

electronic database is available from the authors. We

included unpublished trials retrieved from SIGLE (System

for Information on Grey Literature) database, to reduce

publication bias.

Selection of studies

There were 266 studies identified from electronic databases

and other sources and 20 from additional citation searching

and footnote chasing. Two authors independently reviewed

the abstracts of all 266 studies with the following inclusion

criteria: (1) type of study was randomised controlled trial; (2)

participants should have any kind endoscopic surgery and

there were no exclusions on the basis of type of anaesthesia,

disease, age or gender; (3) type of interventions was room-

temperature irrigation fluid versus warmed irrigation fluid;

we defined the temperature of warmed irrigation fluid as

equal or near to body temperature; (4) studies must measure

at least one of the outcome variables: the incidence of

perioperative hypothermia (£36Æ0 �C) or shivering, body

temperature drop, time to regain initial temperature, blood

loss and (5) We limited language to English or Chinese.

Data extraction

Data were extracted independently by two authors using a

standard data extraction checklist. Data included characteris-

tics of included studies (methods, participants, interventions,

outcomes). Any disagreements were resolved by discussion or

by contacting the original author of study for further informa-

tion or by seeking an independent third opinion.

Assessment of risk of bias in included studies

Two authors evaluated the methodological quality of the

studies for major potential sources of bias using criteria

recommended in Cochrane Library Handbook 5.0.1 (Coch-

rane Handbook for Systematic Reviews of Interventions

Version 5.0.1) (random sequence generation, allocation

concealment, blinding of participants, incomplete outcome

data, selective outcome reporting and other potential

threats to validity). We did not use a scoring or grading

system. Any disagreements were resolved through discus-

sion or by contacting the study author to seek detailed

information.

Data synthesis

We performed a test for heterogeneity of included studies

using RevMan 5.0 software (Review Manager: Computer

program). We expressed each study result as an odds ratio

(OR) for dichotomous data or a weighted mean difference

(WMD) or standard mean difference (SMD) for continuous

data, with 95% confidence intervals (CI). A fixed effect

model was used unless there was significant heterogeneity as

determined by chi-squared test (I2 > 50%), in which case

results were investigated using a random effect model.

When there were different designs, methods or methodo-

logical quality problems potentially interfering with the

results of the review, sensitivity analysis was performed to

seek any influencing factors. We did not plan subgroup

analysis. When data could not be extracted to calculate

total effect, any available data would be reported descrip-

tively.

Results

Of 266 studies screened, 18 studies were retrieved for in-

depth consideration in this study. Five studies were excluded

for the following reasons: (1) one study clearly had the wrong

data (Yi et al. 2005, p. 10) and we failed to contact the

author and (2) four studies (Heathcote & Dyer 1986,

Harioka et al. 1988, Mirza et al. 2007, Board & Srinivasan

2008) were non-randomised controlled trials. Finally, 13

eligible trials (Monga et al. 1996, Pit et al. 1996, Moore

et al. 1997, Kelly et al. 2000, Jaffe et al. 2001, Chen & Tong

2002, Fu et al. 2004, Sun et al. 2006, Okeke 2007, Zeng

et al. 2008, Ding et al. 2009, Kim et al. 2009, Xie et al.

2009) involving 686 patients with an age range from

Review Effects of warmed irrigation fluid on core body temperature


28–95Æ2 years were selected. The endoscopic procedures

used included transurethral resection of the prostate

(TURP); hysteroscopic electric resection of endometrium

(TCRE); minimally invasive percutaneous nephrolithotomy

(MPCNL); laparoscopic surgery and arthroscopic surgery.

The type of anaesthesia was spinal, general or epidural

(Fig. 1).

Characteristics of included trials and methodological

quality

We identified 13 randomised controlled trials. Reporting of

methodological details was not satisfactory. All of these

studies were stated to be randomised, but randomisation

methods are not fully described in 10 of the studies.

Allocation concealment was unclear in all studies. Three of

the trials (Moore et al. 1997, p. 599, Kelly et al. 2000,

p. 248, Kim et al. 2009, p. 25) gave information about the

reasons for incomplete outcome (Tables 1–3).

Perioperative body temperature drop

Figure 2 showed 10 studies reporting body temperature drop

involving 533 patients. Because of the substantial heteroge-

neity (p < 0Æ00001, I2 = 87%), we omitted the pooled

estimate and just performed a narrative synthesis. As shown

in Fig. 2, there was consistency in the direction of effect

which illustrated that room-temperature irrigation fluid could

induce more decrease in mean body temperature than

warmed irrigation fluid.

The incidence of perioperative shivering

Information on incidence of shivering was available for five

studies (312 patients). There were no important heterogeneity

among these studies (p = 0Æ92, I2 = 0%). The incidence of

shivering in group receiving room-temperature fluid was

higher than in group receiving warmed fluid (OR = 5Æ13,

95% CI 2Æ95–10Æ19, p < 0Æ00001) (Fig. 3).

The incidence of perioperative hypothermia

Three studies (103 patients) reported the incidence of

hypothermia. There was substantial heterogeneity between

three studies (p = 0Æ06, I2 = 64%). Compared with room-

temperature group, the warmed irrigation fluid group have a

lower incidence of hypothermia (OR = 22Æ01, 95% CI 2Æ03–

197Æ08, p = 0Æ01) (Fig. 4).

Moore et al.’s (1997) trial was performed on 35 women

undergoing laparoscopic surgery. Laparoscopic surgery

involves an element which is different from arthroscopic

surgery or TURP. Large volumes of gas, most commonly

carbon dioxide, are used to insufflate the peritoneal cavity in

laparoscopic surgery. The cooling effect of insufflation gas is

a cause of hypothermia. A decrease of 0Æ3 degrees in core

temperature was observed for each 50 l of carbon dioxide

delivered (Ott 1991). The total CO2 used in Moore et al.’s

trial is 79 (SD 16) (L) and 82 (SD13) (L), respectively, in two

groups. This may explain the high incidence of hypothermia

in both groups in this trial. Therefore, we excluded this study

to perform sensitivity analysis.

Figure 5 showed that after sensitivity analysis, heteroge-

neity disappeared (p = 0Æ78, I2 = 0%). Significantly more

patients developed hypothermia following the use of room-

temperature irrigation fluid than in the group having warmed

irrigation fluid (OR = 58Æ06, 95% CI 13Æ38–251Æ98, p <

0Æ00001).

Intraoperative blood loss

Figure 6 showed that there was no heterogeneity between

trials (p = 0Æ45, I2 = 0%). Warmed irrigation fluid decreases

blood loss less than room-temperature irrigation fluid

(WMD = 15Æ54 ml, 95% CI 6Æ67–24Æ41, p = 0Æ0006).

Time taken to regain initial temperature

Only one study (Pit et al. 1996) reported time taken to regain

initial temperature. In this study, two sites (rectal and oral)

were used to measure temperature. The result was only just

significant (rectal, p = 0Æ04, t-test) and no significant different

266 identified from electronic databases and other sources

60 citations excluded because duplicate

206 citations selected for further review

20 added from searching additional citations and footnotes

208 citations excluded after first screen because subject and

intervention not related to our review or non-English or

non-Chinese language

18 full-text articles screened for eligibility

5 articles excluded after full text screen, reason for exclusion:

1 had clearly wrong data (Yi et al. 2005, p. 10)

4 non-RCT (Heathcote & Dyer 1986, Harioka et al. 1988,Mirza et al. 2007, Board et al. 2008)

13 articles included in systematic review

Figure 1 Paper review flow chart.

Y Jin et al.


Table

1C

hara

cter

isti

csof

the

tria

lsin

cluded

inth

ere

vie

w

Stu

dy:

auth

ors

,yea

rs,

countr

yT

ype

of

surg

ery

NC

/T

Ages

(yea

rs)

C/T

Tem

per

atu

re

(�C

)of

the

C/T

Type

of

anaes

thes

iaH

eati

ng

equip

men

t

The

site

sof

tem

per

atu

re

mea

sure

men

t

Monga

etal

.(1

996),

USA

TU

RP

14/1

467Æ5

±8Æ4

73Æ4

±8Æ6

22–24/3

5–37

Spin

al/

gen

eral

anaes

thes

ia

Flu

idw

arm

eror

incu

bato

r

Ora

l

Pit

etal

.(1

996),

the

Net

her

lands

TU

RP

31/2

872±

772±

820Æ6

/37Æ5

Spin

al

anaes

thes

ia

Flu

idhea

ter

Rec

tal

and

ora

l

Moore

etal

.(1

997),

USA

Laparo

scopic

surg

ery

16/1

330±

235±

120–22/3

9G

ener

al

anaes

thes

iaPre

ssuri

sed

fluid

war

min

g

syst

em

Oes

ophagea

l

tym

pan

ic

mem

bra

ne

Kel

lyet

al.

(2000),

Phil

ippin

es

Knee

art

hro

scopy

surg

ery

9/1

135Æ5

±7Æ8

37Æ8

±11Æ6

20Æ7

5/4

0Spin

al

anaes

thes

iaW

arm

ing

cabin

etT

ympanic

mem

bra

ne

Jaff

eet

al.

(2001),

USA

TU

RP

27/2

971Æ5

±8Æ2

70Æ9

±8Æ0

21/3

3–

–T

ympanic

mem

bra

ne

Chen

&T

ong

(2002),

Chin

aT

UR

P30/3

070Æ5

68Æ8

19–22/3

6Æ8

–37Æ5

Epid

ura

l/gen

eral

anaes

thes

ia

Incu

bato

rR

ecta

l

Fu

etal

.(2

004),

Chin

aT

UPR

31/3

167

21–24/3

7–38

Epid

ura

lanae

sthes

iaH

otl

ine

hea

ter

Rec

tal

Sun

etal

.(2

006),

Chin

aT

UR

P30/3

468±

665±

521/3

7E

pid

ura

l/sp

inal

anaes

thes

ia

Incu

bato

r–

Okek

e(2

007),

Nig

eria

TU

RP

40/4

075Æ9

±20Æ2

76Æ1

±19Æ1

27±

5/3

8–

–O

ral

Zen

get

al.

(2008),

Chin

aM

PC

NL

30/3

046Æ1

7±

10Æ8

846Æ4

0±

9Æ3

123±

1/3

5±

1E

pid

ura

lanae

sthes

iaIn

cubato

rR

ecta

l

Din

get

al.

(2009),

Chin

aT

CR

E33/3

346Æ0

±2Æ1

24–27/3

7In

trave

nous

anaes

thes

ia–

–

Xie

etal

.(2

009),

Chin

aT

UR

P28/2

865±

3Æ0

22–24/3

6–38

Epid

ura

lanae

sthes

iaIn

cubato

rR

ecta

l

Kim

etal

.(2

009),

Kore

aShould

er

art

hro

scopy

surg

ery

23/2

350Æ4

±14Æ5

45Æ8

±13Æ3

20–22/3

7–39

Gen

eral

anaes

thes

iaFlu

idhea

ter

Oes

ophagea

l

C,

contr

ol

gro

up

(room

-tem

per

atu

reir

rigat

ion

fluid

);T

,tr

eate

dgro

up

(warm

edir

rigat

ion

fluid

);T

UR

P,

transu

reth

ral

rese

ctio

nof

the

pro

state

;T

CR

E,

hyst

erosc

opic

elec

tric

rese

ctio

nof

endom

etri

um

;M

PC

NL

,m

inim

all

yin

vasi

ve

per

cuta

neo

us

nep

hro

lith

oto

my.



Table

2C

hara

cter

isti

csof

the

tria

lsin

cluded

inth

ere

vie

w

Stu

dy:

auth

ors

,yea

rs,

countr

ySurg

ical

tim

e(m

in)

C/I

Tota

lir

rigat

ing

fluid

(l)

C/I

Outc

om

es

Monga

etal

.(1

996),

USA

––

––

The

inci

den

ceof

hypoth

erm

ia;

body

tem

per

atu

re

Pit

etal

.(1

996),

the

Net

her

lands

66±

22

77±

25

––

Body

tem

per

atu

re;

tim

eto

regain

init

ial

tim

e;

haem

oglo

bin

;re

sect

edw

eight;

the

pati

ent

num

-

ber

sof

feel

ing

cold

Moore

etal

.(1

997),

USA

96±

890±

10

1481±

231

(ml)

1264±

231

(ml)

The

inci

den

ceof

hypoth

erm

ia;

body

tem

per

atu

re

bel

ow

base

line;

tota

lC

O2

use

d

Kel

lyet

al.

2000,

Phil

ippin

es45Æ6

±20Æ1

44Æ3

±22Æ6

11Æ7

±10Æ7

11Æ8

±11Æ0

Mea

nper

cent

body

tem

per

atu

redec

rease

Jaff

eet

al.

(2001),

USA

102Æ2

±30Æ6

96Æ8

±27Æ9

17

333±

1226

(ml)

17

596±

1013

(ml)

The

inci

den

ceof

dec

rease

dte

mper

atu

re;

body

tem

per

atu

re;

rese

cted

wei

ght

Chen

&T

ong

(2002),

Chin

a58

78

23

000

(ml)

33

000

(ml)

Body

tem

per

atu

re;

the

inci

den

ceof

shiv

erin

g

Fu

etal

.(2

004),

Chin

a75±

11

70±

920

000

(ml)

Body

tem

per

atu

re;

the

inci

den

ceof

shiv

erin

g;

blo

od

pre

ssure

;th

epati

ent

num

ber

sof

feel

ing

cold

Sun

etal

.(2

006),

Chin

a30–90

30–120

23

500

(ml)

25

000

(ml)

The

inci

den

ceof

shiv

erin

g;blo

od

pre

ssure

;

rese

cted

wei

ght;

hea

rtra

te

Okek

e(2

007),

Nig

eria

51±

22

49±

17

20Æ3

±7

22Æ2

±3

The

inci

den

ceof

shiv

erin

g;body

tem

per

atu

re

bel

ow

base

line;

the

num

ber

of

feel

ing

cold

:th

e

mea

nti

me

of

post

oper

ati

ve

hosp

ital

stay

Zen

get

al.

(2008),

Chin

a48Æ3

±21Æ0

46Æ7

±19Æ0

––

Body

tem

per

atu

re;

blo

od

loss

Din

get

al.

(2009),

Chin

a37Æ6

±12Æ0

32Æ6

±15Æ2

4020±

1130

(ml)

39

800±

1320

(ml)

Blo

od

loss

;am

ount

of

liquid

abso

rpti

on;

seru

m

sodiu

m,

pota

ssiu

m,

ure

anit

rogen

;anio

ngap;

tem

per

atu

re;

rese

cted

wei

ght

Xie

etal

.(2

009),

Chin

a68±

10

71±

920

000

(ml)

Body

tem

per

atu

re;

blo

od

loss

;blo

od

pre

ssure

;

hea

rtra

te

Kim

etal

.(2

009),

Kore

a91Æ1

±32Æ4

94Æ5

±21Æ9

10Æ3

±4Æ3

9Æ8

±3Æ2

Haem

oglo

bin

;te

mper

atu

re;

hypoth

erm

ia;

shiv

erin

g;

post

oper

ati

vepain

(VA

S);

post

oper

ati

ve

wei

ght

gain

C,

contr

ol

gro

up

(room

-tem

per

ature

irri

gat

ion

fluid

);I,

inte

rven

tion

gro

up

(warm

ed-t

emper

atu

reir

rigati

on

fluid

).

Y Jin et al.


Table 3 Methodological quality of included trials

Study: authors, years, country Sequence generation

Allocation

concealment Blinding

Incomplete

outcomes

data

Selective

outcome

reporting

Other potential

threats to

validity

Monga et al. (1996), USA Unclear Unclear Single-blind No Unclear Unclear

Pit et al. (1996), the Netherlands Unclear Unclear Single-blind No Unclear Unclear

Moore et al. (1997), USA Random numbers table Unclear Unclear Yes Unclear Unclear

Kelly et al. (2000), Philippines Random numbers table Unclear Unclear Yes Unclear Unclear

Jaffe et al. (2001), USA Unclear Unclear Double-blind No Unclear Unclear

Chen & Tong (2002), China Unclear Unclear Unclear No Unclear Unclear

Fu et al. (2004), China Unclear Unclear Unclear No Unclear Unclear

Sun et al. (2006), China Unclear Unclear Unclear No Unclear Unclear

Okeke (2007), Nigeria Picking a ballot Unclear Unclear No Unclear Unclear

Zeng et al. (2008), China Unclear Unclear Unclear No Unclear Unclear

Ding et al. (2009), China Unclear Unclear Unclear No Unclear Unclear

Xie et al. (2009), China Random number table Unclear Unclear No Unclear Unclear

Kim et al. (2009), Korea Unclear Unclear Observer Yes Unclear Unclear

Room-temperatureStudy or subgroup Mean MeanSD SDTotal Total Weight

Std. Mean differenceIV, Fixed, 95% CI

Std. Mean differenceIV, Fixed, 95% CI

Chen 2002Fu 2004Jaffe 2001Kim 2009Monga 1996Moore 1997Okeke 2007Pit 1996Xie 2009Zeng 2008

1·511·60·020·860·951·70·981·711·50·71

0·480·4160·750·20·470·20·561·10·360·45

30312723141640302830

0·410·80·10·280·4210·420·740·80·14

0·450·3570·630·20·640·20·210·60·340·3

30312923141340262830

2·33 [1·67, 3·00]2·04 [1·42, 2·66]

–0·11 [–0·64, 0·41]2·85 [2·01, 3·69]0·92 [0·13, 1·70]3·40 [2·21, 4·59]1·31 [0·83, 1·80]1·06 [0·50, 1·62]1·97 [1·32, 2·62]1·47 [0·90, 2·05]

–4 –2 0 2 4

Warmed

Figure 2 Perioperative body temperature

drop for room-temperature group and

warmed group; standard mean difference

with 95% confidence interval (CI).

Room-temperatureStudy or subgroup Total Total Weight

Warmed Odds ratioM-H, Fixed, 95% CI

Odds ratioM-H, Fixed, 95% CIEventsEvents

Chen 2002Fu 2004Kim 2009Okeke 2007Sun 2006

Total (95% CI)

Total events

695

1312

45

154

3040233130 2

2035

3031234034

19·4%17·2%

4·7%24·6%34·1%

158 100·0%

12

5·13 [2·59, 10·19]

3·50 [0·65, 18·98]5·93 [1·16, 30·25]

13·97 [0·73, 269·23]5·94 [1·54, 22·90]3·87 [1·17, 12·81]

0·001 0·1 1 10 1000Heterogeneity: c2 = 0·93, df = 4 (p = 0·92); l2 = 0%Test for overall effect Z = 4·68 (p < 0·00001)

Figure 3 The incidence of perioperative

shivering for room-temperature group and

warmed group; odds ratio (OR) with 95%

CI.

Room-temperatureStudy or subgroup Events Total Total

WarmedEvents Weight

Odds ratioM-H, Random, 95% CI

Odds ratioM-H, Random, 95% CI

Kim 2009

Monga 1996

Moore 1997

Total (95% CI)

Total events

Heterogeneity: t2 = 2·60; c2 = 5·56, df = 2 (p = 0·06); I2 = 64%Test for overall effect: Z = 2·57 (p = 0·01)

21 23 4 23

14

13

50

2

12

18

14

16

53

13

15

49

39·4%

31·9%

28·6%

100·0%

49·88 [8·18, 303·93]

78·00 [6·24, 974·71]

1·25 [0·07, 22·13]

20·01 [2·03, 197·08]

0·001 0·1 1 10 1000

Figure 4 The incidence of perioperative

hypothermia for room-temperature group

and warmed group; OR with 95% CI.

Room-temperatureStudy or subgroup Events Total Total

WarmedEvents Weight

Odds ratioM-H, Fixed, 95% CI

Odds ratioM-H, Fixed, 95% CI

Kim 2009

Monga 1996

21 23 4 23

1421413

70·9%

29·1%

49·88 [8·18, 303·93]

78·00 [6·24, 974·71]

Total (95% CI) 37 37 100·0% 58·06 [13·38, 251·98]

Total events 634

0·001 0·1 1 10 1000Heterogeneity: c2 = 0·08, df = 1 (p = 0·78); I2 = 0%Test for overall effect: Z = 5·42 (p < 0·00001)

Figure 5 Sensitivity analysis of the inci-

dence of perioperative hypothermia for

room-temperature group and warmed

group; OR with 95% CI.



(oral, p = 0Æ07, t-test) between the population who received

room-temperature irrigating fluid and those who received

warmed irrigating fluid. The available evidence did not show

warmed irrigation fluid can decrease the time to regain initial

temperature.

Discussion

In this meta-analysis, although the quality of the studies in

this review is not satisfactory, it is possible to draw the

conclusion that during endoscopic surgery, warmed irrigation

fluid can decrease heat loss, shivering and hypothermia and it

also decreases the blood loss. Therefore, the use of warmed

irrigation fluid is of benefit during endoscopic surgery.

There was heterogeneity between 10 studies about body

temperature drop. Differences in the temperature and volume

of irrigating fluids (Tables 1 and 2) or differences in supple-

mentary heating methods used for the patients could have

affected outcomes and resulted in heterogeneity. There are

two studies that used warming mattress or blankets for every

patient in both control group and treated group in addition to

warmed irrigation fluid for treated group. Jaffe et al. (2001)

reported that the patients were covered with a gown and a

warm blanket (45 �C) from their neck to the level of their

umbilicus to help protect against heat loss during the

procedure. Moore et al.’s trial (1997, p. 599) reported that

the patient lay on a heating blanket set at 37Æ8 �C. The fact

that they actively warmed patients during operation could

interfere with the effect of warmed irrigation fluid. However,

from the forest plot, we can see that the majority of the

studies did show that using warmed irrigating fluid decreased

body temperature drop.

It is worth noting that Jaffe et al. (2001) and Kelly et al.

(2000, p. 249) contest the conclusion that warm irrigating

fluid can maintain a higher body temperature. Kelly et al.

reported that the group receiving warmed irrigating solution

tended to have a greater decline in temperature than the

control group (although there was no statistically significant

difference in mean percent temperature decrease from base-

line between groups). The authors explain that this trend may

be because of heat loss associated within knee joint tissues.

Subsequent infusion of warm irrigation solution into knee

joints may actually increase heat loss by exacerbating or

extending the duration of vasodilatation associated with

spinal-induced sympathectomy. The sample size of this study

is small (n = 20), so further study is needed to verify this

result. Body temperature decrease in this study is reported in

percent (%) temperature decrease from baseline which is

different with other studies and could not be used for

calculating combined effect size. Jaffe et al. also suggest that

irrigation fluid temperature is not a factor responsible for

altering the core body temperature in patients undergoing

TURP, they also reported that 20 (35Æ7%) from a total 56

patients demonstrated an increase in core body temperatures

after TURP. This result was neither expected nor reported by

the other included studies. A factor that may have contrib-

uted to the observed elevation in body temperature is the

rigorous use of the warming blankets (45 �C) both intraop-

eratively and postoperatively to assist the patients in main-

taining their core body temperature.

Two other aspects of the study design warrant special

attention:

1 Core temperature is the best indicator of body tempera-

ture. Therefore, all non-core sites need to be judged by

their ability to accurately access core temperature (Kurz

2008, p. 52). The included studies used different methods

of temperature measurement. Most studies claimed that

their methods or sites of temperature measurement reflect

core body temperature. So far, there is not agreement

about the most accurate method of core body temperature

monitoring during anaesthesia. The invasive measurement

in the pulmonary artery is regarded as the gold standard

for core temperature determination (Kurz 2008, p. 52). A

systematic review by Hooper and Andrews (2006, p. 33)

reported that infrared ear temperature measurement can

not be recommended for perioperative use, because of its

poor performance. Oral temperature has proved an accu-

rate surrogate for core temperature, although it provides a

value below actual core body temperature of around 0Æ2–

0Æ3 �C (Hooper & Andrews 2006, p. 31). The result of a

review (Kurz 2008, p. 53) also suggested that tympanic

infrared thermometers, infrared temporal artery measure-

ments, peripheral skin temperatures are not recommended.

ASPAN’s clinical practice guideline stated available ‘near-

Room-temperatureStudy or subgroup Mean MeanSD SDTotal Total Weight

Mean differenceIV, Fixed, 95% CI

Mean differenceIV, Fixed, 95% CI

Warmed

Xie 2009

Ding 2009

Zeng 2008

428

262

52·33

273

42·2

25·4

33

28

30

456

235

38·83

291

41·3

9·69

33

28

30

0·4%

16·4%

83·1%

–28·00 [–164·14, 108·14]

27·00 [5·13, 48·87]

13·50 [3·77, 23·23]

Total (95% CI) 91 91 100·0% 15·54 [6·67, 24·41]

Heterogeneity: c2 =1·62, df = 2 (p = 0·45); I2 = 0%Test for overall effect: Z = 3·43 (p = 0·0006) –50 –25 0 25 50

Figure 6 Intraoperative blood loss for

room-temperature group and warmed

group; weight mean difference with 95%

CI.

Y Jin et al.


core’ measures (e.g., oral, bladder, rectal, temporal artery,

tympanic membrane) must be relied on to evaluate thermal

balance across much of the perianaesthesia/perioperative

period. Unfortunately, each near-core measure has limita-

tions in the ability to reflect core temperature. Overall, the

research on perianaesthesia temperature measurement is

weak because of lack of controls, insufficient statistical

analysis and lack of replication (Hooper et al. 2009, p.

275). So, further research is needed to develop non-inva-

sive and unified temperature monitoring devices for core

temperature during anaesthesia.

2 In included studies, patients who underwent transurethral

resection were generally older. Harioka et al. (1988,

p. 328) suggest that older people tend to exhibit more

pronounced and prolonged hypothermia. However, Pit

et al. (1996, p. 100) reported that there was no relation-

ship between the degree of cooling and the age or body

weight of the patients. Kim et al. (2009, p. 27) also claimed

that core body temperature did not correlate with the

patient’s age in the warmed fluid group. Further research is

needed to solve this controversial issue.

From Fig. 2, we find it is clear that core body temperature

of both control and treated groups in all the above-mentioned

studies decreased throughout the intraoperative period. This

means that the use of warmed irrigation fluid can decrease,

but not eliminate, temperature drop. Continued heat loss in

the group of patients receiving warmed irrigation fluid may

have been augmented by local vasodilatation of vascular beds

because of the infusion of warmed irrigation fluid and

transfer of heat from blood to surrounding tissues and to the

environment. The clinical implications of even a small degree

of hypothermia may be significant.

Most of studies devised some methods to provide warmed

irrigating fluid at a constant temperature with minimal

interference, then ensure the effectiveness of the trials. The

temperature of warmed irrigation fluid in studies reviewed

ranged from 33–40 �C, so it would not cause burn injure.

There were not any significant negative side-effects in all

reports of included studies.

Limitations of this review

1 One limitation of this review is the low number of eligible

studies, especially those reporting the incidence of hypo-

thermia and the time to regain initial temperature as

outcomes. In addition, small sample size limits the appli-

cability of several study findings. Some results may not be

shown because of small sample size.

2 Methodological quality of included studies was low. It

may lead to some selection and performance bias. The

problems encountered were lack of allocation conceal-

ment, ITT analysis and partial use of blinding. These

problems might be the source of bias which threatens the

validity of the reported results. Two of the included

studies (Fu et al. 2004, p. 44, Okeke 2007) measured

subjective indicators like feeling cold. Although one study

reported blinding of patients, it is desirable for subjective

indicators to have blinding of participants and outcome

assessors.

3 Our search strategy may have missed some relevant studies

by only including English and Chinese publications.

However, we did not find related literatures in languages

other than English and Chinese. So the language aspect of

the search strategy may not have impacted the validity of

our results.

In view of these limitations, we applied strict inclusion

criteria to our study, and we also systematically explored the

issue of heterogeneity by use of sensitivity analysis. These

methodological strengths have therefore enhanced the valid-

ity and applicability of our findings. Prospective, large sample

size, well-designed, double-blind RCTs are needed to verify

these findings.

4 The limited studies precluded meaningful subgroup anal-

ysis (based on variations in the amount of fluid or different

degree of warming of irrigating fluid), which is important,

given the heterogeneity of the study.

Conclusions and relevance to clinical practice

Although there were some limitations in the above-men-

tioned included studies, the result does indicate that the use of

warmed irrigating fluid is a reasonable means of decreasing

heat loss and the risk of perioperative shivering and hypo-

thermia, which suggests nurses should actively use warm

fluids for irrigation during endoscopic surgeries.

However, the decision on whether or not to warm

irrigation fluids is made by surgeons, not anaesthetists or

intensive care specialists in most of countries. So, it is critical

to raise awareness about the importance of intraoperative

temperature management in all surgical specialists. Nurses

and other surgical specialities should unite and reach a

consensus on implementing warming irrigating and other

effective warming methods to maintain normothermia in

patients throughout endoscopic surgeries.

Acknowledgements

The authors gratefully acknowledge help by Jean Glover and

Weijie Gao of the Nursing Department of Tianjin Medical

University for their aid in revising the paper.



Contributions

Study design: KHY, MS; data collection and analysis: YHJ,

MS and manuscript preparation: YHJ, JHT.

Conflict of interest

We declared that we had no financial and personal relation-

ships with other people or organisations that can inappro-

priately influence our work.

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7000 libraries worldwide (including over 4000 in developing countries with free or low cost access).

Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.

Early View: rapid online publication (with doi for referencing) for accepted articles in final form, and fully citable.

Positive publishing experience: rapid double-blind peer review with constructive feedback.

Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley

Online Library, as well as the option to deposit the article in your preferred archive.

Y Jin et al.


This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy.

Users should refer to the original published version of the material.

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