Prävention von Hypothermie

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Körperkerntemperatur (Normothermie) liegt bei +37 °C. Dabei können zwischen dem Körperkern und der körperlichen Peripherie, wie etwa den Extremitäten, Temperaturunterschiede von bis zu 4 °C auftreten [1] und im Tagesverlauf variieren. Daher wird ein Temperaturbereich von 36,0 °C bis 37,5 °C als normotherm bezeichnet. [2]</p> </div> </div> </div> </section> </div> </div> </div> </div> </section>  <div class="container"> <div class="row"> <div class="col-12"> <section class='block__center'> <p>Eine Hypothermie, also eine Untertemperatur, liegt ab Werten von unter 36°C vor. Hierbei wird in drei Stadien unterschieden:<br /></p></section> <section class="block__numbers"> <div class="numbers__center"> <div class="numbers__item"> <span class="">Mild:</span> <p>< 36°C – 33°C</p> </div> <div class="numbers__item"> <span class="">Medium:</span> <p>33°C – 28°C</p> </div> <div class="numbers__item"> <span class="">Schlimm:</span> <p>< 28°C</p> </div> </div> </section> <section class='block__center'> <h3>Steuerung der Körpertemperatur durch das Gehirn</h3> <p>Der Hypothalamus steuert die Körperkerntemperatur mit Hilfe von Thermorezeptoren, die in der Haut, im Rückenmark, im Gehirn und im tiefen zentralen Nervengewebe verortet sind [1] [3].</p> <h3>Körperliche Erhaltungsmechanismen der Normothermie</h3> <p>Für die Aufrechterhaltung der Körpertemperatur verfügt der Körper über verschiedene Mechanismen. Bei gesunden Menschen wird die Kerntemperatur mit einer Toleranz von etwa ±0,2 °C reguliert. Diese schmalen Grenzen oberhalb und unterhalb des 37 °C-Sollwerts definieren den Interthreshold-Bereich, also die akzeptablen Grenzen der Körpertemperatur. Wenn äußere Faktoren die Kerntemperatur über diesen Bereich hinaustreiben, ergreift der Körper Korrekturmaßnahmen.</p> <ul class="on-list"> <li><strong>Vasokonstriktion:</strong> Kleine Blutgefäße in der Nähe der Hautoberfläche verengen sich, wodurch der Blutfluss und damit der Wärmeverlust verringert wird.</li> <li><strong>NST:</strong> "Non shivering thermogenesis", ist eine Erhöhung der Stoffwechselrate, die vor allem bei Säuglingen auftritt.</li> <li><strong>Zittern:</strong> Hierbei handelt es sich um unwillkürliche Muskelkontraktionen, die Wärme erzeugen. Da es große Mengen an Energie verbraucht, ist es das letzte Mittel des Körpers, wenn andere Strategien versagen. [1][3]</li> </ul> <p>Wenn der Wärmeverlust geringer als erforderlich ist, der Körper also zu warm wird, reagiert der Körper mit:</p> <ul class="on-list"> <li><strong>Vasodilatation:</strong> Kleine Blutgefäße in der Nähe der Hautoberfläche weiten sich, wodurch sich der Blutfluss erhöht und überschüssige Wärme abgeleitet wird.</li> <li><strong>Schwitzen:</strong> Der Körper scheidet Flüssigkeit aus, die verdunstet und die Hautoberfläche abkühlt. [1][3] <br /></li> </ul> <h3>Hypothermie unter Narkose</h3> <p>Normalerweise produziert eine 40-jährige Person im Wachzustand etwa 70 Kilokalorien Wärme pro Stunde. Im narkotisierten Zustand sinkt die metabolische Wärmeproduktion derselben Person auf etwa 42 Kilokalorien pro Stunde. [4]</p> <p>Unter Narkose ist die Fähigkeit des Hypothalamus, die Temperatur zu regulieren, also beeinträchtigt und der Bereich zwischen den Schwellenwerten erweitert sich auf 4 °C. Infolgedessen sind narkotisierte Patienten nicht mehr in der Lage, ihre Körpertemperatur zu regulieren. Der Patient wird wärmer oder kälter, bevor die thermoregulatorischen Reaktionen ausgelöst werden. [1][3]</p> <p>Während einer Narkose löst die Hypothermie des Patienten eine Vasokonstriktion aus, die aufgrund der häufig verabreichten Muskelrelaxanzien nicht zum Zittern führt. Unter dem Einfluss der Anästhesie wird die Schwelle für die Vasokonstriktion so weit herabgesetzt, dass die arteriovenösen Shunts, die sich vor allem in den Fingern, Zehen und der Nase befinden, geöffnet werden. Das Blut fließt ungehindert in die Peripherie und der Körper kann das Temperaturgefälle zwischen dem Kern und der Peripherie nicht mehr aufrechterhalten. [1] <br /></p> <h3>Beeinträchtigung der Thermoregulation durch eine Narkose</h3> <p>Patienten unter Vollnarkose sind nicht in der Lage, ihre Körperkerntemperatur durch ihr Verhalten auf den optimalen Sollwert zu regulieren und müssen sich auf ihr autonomes Thermoregulationssystem verlassen. Das autonome Thermoregulationssystem des Körpers ist jedoch unter Narkose in seiner Leistungsfähigkeit beeinträchtigt.</p> <p>Die Narkosemittel hemmen das autonome System, indem sie den Stoffwechsel reduzieren und die thermoregulatorische Reaktion unterdrücken. [3] <br /></p> <h3>Hauptursachen einer perioperativen Hypothermie</h3> <ul class="on-list"> <li>die Verabreichung von Narkosemitteln während der Vollnarkose</li> <li>die in den meisten Operationssälen herrschenden kühlen Temperaturen</li> <li>freiliegende Körperteile und Einschnitte während der Operation</li> <li>die Infusion von kalten Flüssigkeiten und Blut</li> </ul> <p>Der Wärmeverlust wird durch die kalte Umgebung in den meisten Operationssälen noch verschärft. Die Raumtemperatur beträgt in der Regel 16,0 °C  - 21,0 °C. [1][5] <br /></p> <h3>Thermodynamik</h3> <p>Nach den Gesetzen der Thermodynamik bewegt sich Wärme immer von einem wärmeren Bereich oder Gegenstand zu einem kälteren Bereich oder Gegenstand. Somit geht ein erheblicher Teil der Körperwärme des Patienten an die viel kühlere Umgebung des Operationssaals verloren.</p> <p>Der chirurgische Eingriff selbst führt zu einem erhöhten Wärmeverlust des Patienten. Während der Operation und der Operationsvorbereitung sind große Hautflächen der kühlen Umgebung ausgesetzt. Chirurgische Schnitte, bei denen die inneren Organe der kalten OP-Luft ausgesetzt sind, führen häufig zu einer tiefen inneren Unterkühlung, die den natürlichen Wärmetransfer noch verstärken. <br /></p> <h3>Effekte von ungewollter Hypothermie</h3> <p>Negative Auswirkungen einer unbeabsichtigten perioperativen Hypothermie sind u.a.:</p> <ul class="on-list"> <li>Wundinfektion</li> <li>Myokardiale Ischämie und kardiale Störungen</li> <li>Koagulopathie</li> <li>Verlängerte und veränderte Arzneimittelwirkung</li> <li>Erhöhte Sterblichkeit</li> <li>Schüttelfrost und thermisches Unbehagen</li> <li>verzögertes Aufwachen aus der Narkose [5] <br /></li> </ul> <h3>Positive Effekte durch Erhaltung der Normothermie</h3> <p>Die Aufrechterhaltung der Normothermie kann zu positiven Ergebnissen führen, wie z. B.:</p> <ul class="on-list"> <li>Verringerung der Wundinfektionsrate</li> <li>Geringere Wahrscheinlichkeit eines Myokardinfarkts</li> <li>Verkürzte Dauer der Intensivstation</li> <li>Verkürzte Aufenthaltsdauer</li> <li>Geringere Sterblichkeitsrate</li> <li>Geringerer Einsatz von Blutprodukten</li> <li>Geringere Wahrscheinlichkeit, dass eine Transfusion erforderlich ist</li> <li>Die Einsparungen können zwischen $2.500 und $7.000 pro Patient liegen [6]</li> </ul> <p>Daher ist es erstrebenswert, eine normotherme Temperatur perioperativ zu erhalten. Dafür eignen sich vorgewärmte Decken und Heizsysteme sowie das Erwärmen von Flüssigkeiten wie Infusionen, EK, FFP, etc. vor Verabreichung.[6] <br /></p> <section class="linie color--grey"></section> <p><strong>Quellen:</strong><br /></p> <p><sup>1) Sessler DI. Current concepts: Mild Perioperative Hypothermia. <em>New Engl J Med.</em> 1997;336(24):1730-1737.</sup> <br /><sup>2) Bräuer, Perioperatives Wärmemanagement, Der Anästhesist 2007</sup> <br /><sup>3) Guyton AC, Hall JE. <em>Textbook of Medical Physiology.</em> 10th Ed. © 2000.</sup> <br /><sup>4) Morrison RC. Hypothermia in the elderly. <em>International Anesthesiology Clinics.</em> 1988;26(2):124-133.</sup> <br /><sup>5) Sessler DI, Kurz A. Mild Perioperative Hypothermia. <em>Anesthesiology News.</em> October 2008: 17-28.</sup> <br /><sup>6) Mahoney CB, Odom J. 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