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Copyright, 1996, by the Massachusetts Medical Society

Volume 334 MAY 9, 1996 Number 19

PERIOPERATIVE NORMOTHERMIA TO REDUCE THE INCIDENCE OF SURGICAL-WOUND


INFECTION AND SHORTEN HOSPITALIZATION
ANDREA KURZ, M.D., DANIEL I. SESSLER, M.D., AND RAINER LENHARDT, M.D.,
FOR THE S TUDY OF W OUND I NFECTION AND T EMPERATURE G ROUP *

Abstract Background. Mild perioperative hypothermia, infected. The patients surgeons remained unaware of
which is common during major surgery, may promote sur- the patients group assignments.
gical-wound infection by triggering thermoregulatory vas- Results. The mean (SD) nal intraoperative core
oconstriction, which decreases subcutaneous oxygen temperature was 34.70.6C in the hypothermia group
tension. Reduced levels of oxygen in tissue impair oxida- and 36.60.5C in the normothermia group (P0.001).
tive killing by neutrophils and decrease the strength of Surgical-wound infections were found in 18 of 96 patients
the healing wound by reducing the deposition of col- assigned to hypothermia (19 percent) but in only 6 of 104
lagen. Hypothermia also directly impairs immune func- patients assigned to normothermia (6 percent, P  0.009).
tion. We tested the hypothesis that hypothermia both in- The sutures were removed one day later in the patients
creases susceptibility to surgical-wound infection and assigned to hypothermia than in those assigned to nor-
lengthens hospitalization. mothermia (P  0.002), and the duration of hospitalization
Methods. Two hundred patients undergoing colorec- was prolonged by 2.6 days (approximately 20 percent) in
tal surgery were randomly assigned to routine intraoper- the hypothermia group (P  0.01).
ative thermal care (the hypothermia group) or additional Conclusions. Hypothermia itself may delay healing
warming (the normothermia group). The patients anes- and predispose patients to wound infections. Maintaining
thetic care was standardized, and they were all given normothermia intraoperatively is likely to decrease the in-
cefamandole and metronidazole. In a double-blind proto- cidence of infectious complications in patients undergo-
col, their wounds were evaluated daily until discharge ing colorectal resection and to shorten their hospitaliza-
from the hospital and in the clinic after two weeks; tions. (N Engl J Med 1996;334:1209-15.)
wounds containing culture-positive pus were considered 1996, Massachusetts Medical Society.

W OUND infections are common and serious com-


plications of anesthesia and surgery. A wound in-
fection can prolong hospitalization by 5 to 20 days and
desired, intraoperative hypothermia is usual because
few patients are actively warmed.8
Hypothermia may increase patients susceptibility to
substantially increase medical costs.1,2 In patients under- perioperative wound infections by causing vasoconstric-
going colon surgery, the risk of such an infection ranges tion and impaired immunity. The presence of sufcient
from 3 to 22 percent, depending on such factors as the intraoperative hypothermia triggers thermoregulatory
length of surgery and underlying medical problems.3 vasoconstriction,9 and postoperative vasoconstriction is
Mild perioperative hypothermia (approximately 2C be- universal in patients with hypothermia.10 Vasoconstric-
low the normal core body temperature) is common in tion decreases the partial pressure of oxygen in tissues,
colon surgery.4 It results from anesthetic-induced im- which lowers resistance to infection in animals11,12 and
pairment of thermoregulation,5,6 exposure to cold, and humans (unpublished data). There is decreased micro-
altered distribution of body heat.7 Although it is rarely bial killing, partly because the production of oxygen
and nitroso free radicals is oxygen-dependent in the
range of the partial pressures of oxygen in wounds.13,14
From the Thermoregulation Research Laboratory and the Department of An-
esthesia, University of California, San Francisco (A.K., D.I.S.); and the Depart- Mild core hypothermia can also directly impair immune
ments of Anesthesiology and General Intensive Care, University of Vienna, Vi- functions, such as the chemotaxis and phagocytosis of
enna, Austria (A.K., D.I.S., R.L.). Address reprint requests to Dr. Sessler at the granulocytes, the motility of macrophages, and the pro-
Department of Anesthesia, 374 Parnassus Ave., 3rd Fl., University of California,
San Francisco, CA 94143-0648. duction of antibody.15,16 Mild hypothermia, by decreas-
Supported in part by grants (GM49670 and GM27345) from the National In- ing the availability of tissue oxygen, impairs oxidative
stitutes of Health, by the Joseph Drown and Max Kade Foundations, and by Au-
gustine Medical, Inc. The authors do not consult for, accept honorariums from,
killing by neutrophils. And mild hypothermia during
or own stock or stock options in any company whose products are related to the anesthesia lowers resistance to inoculations with Escher-
subject of this research. ichia coli17 and Staphylococcus aureus18 in guinea pigs.
Presented in part at the International Symposium on the Pharmacology of Ther-
moregulation, Giessen, Germany, August 1722, 1994, and at the Annual Meeting Vasoconstriction-induced tissue hypoxia may decrease
of the American Society of Anesthesiologists, Atlanta, October 2125, 1995. the strength of the healing wound independently of its
*The study investigators are listed in the Appendix. ability to reduce resistance to infection. The formation

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1210 THE NEW ENGLAND JOURNAL OF MEDICINE May 9, 1996

of scar requires the hydroxylation of abundant pro- hour for the subsequent 24 hours. Leukocyte-depleted blood was ad-
line and lysine residues to form the cross-links between ministered as the attending surgeon considered appropriate.
At the time of the induction of anesthesia, each patient was ran-
strands of collagen that give healing wounds their ten- domly assigned to one of the following two temperature-manage-
sile strength.19 The hydroxylases that catalyze this re- ment groups with computer-generated codes maintained in num-
action are dependent on oxygen tension,20 making col- bered, sealed, opaque envelopes: the normothermia group, in which
lagen deposition proportional to the partial pressure of the patients core temperatures were maintained near 36.5 C, and the
hypothermia group, in which the core temperature was allowed to de-
arterial oxygen in animals21 and to oxygen tension in crease to approximately 34.5C. In both groups, intravenous uids
wound tissue in humans.22 were administered through a uid warmer, but the warmer was acti-
Although safe and inexpensive methods of warming vated only in the patients assigned to extra warming. Similarly, a
are available,8 perioperative hypothermia remains com- forced-air cover (Augustine Medical, Eden Prairie, Minn.) was po-
mon.23 Accordingly, we tested the hypothesis that mild sitioned over the upper body of every patient, but it was set to de-
liver air at the ambient temperature in the hypothermia group and
core hypothermia increases both the incidence of sur- at 40 C in the normothermia group. Cardboard shields and sterile
gical-wound infection and the length of hospitalization drapes were positioned in such a way that the surgeons could not dis-
in patients undergoing colorectal surgery. cern the temperature of the gas inating the cover. Shields were also
positioned over the switches governing the uid heater and the
METHODS forced-air warmer so that their settings were not apparent to the op-
With the approval of the institutional review board at each partic- erating-room personnel. The temperatures were not controlled post-
ipating institution and written informed consent from the patients, we operatively, and the patients were not informed of their group assign-
studied patients 18 to 80 years of age who underwent elective colorec- ments.
tal resection for cancer or inammatory bowel disease. Patients sched- Supplemental oxygen was administered through nasal prongs at a
uled for abdominalperitoneal pull-through procedures were includ- rate of 6 liters per minute during the rst three postoperative hours
ed, but not those scheduled for minor colon surgery (e.g., polypectomy and was then gradually eliminated while oxygen saturation was main-
or colostomy performed as the only procedure). The criteria for ex- tained at more than 95 percent. To minimize the decrease in wound
clusion from the study were any use of corticosteroids or other immu- perfusion due to activation of the sympathetic nervous system, post-
nosuppressive drugs (including cancer chemotherapy) during the four operative pain was treated with piritramide (an opioid), the adminis-
weeks before surgery; a recent history of fever, infection, or both; se- tration of which was controlled by the patient.
rious malnutrition (serum albumin, less than 3.3 g per deciliter, a The attending surgeons, who were unaware of the patients group
white-cell count below 2500 cells per milliliter, or the loss of more assignments and core temperatures, determined when to begin feed-
than 20 percent of body weight); or bowel obstruction. ing them again after surgery, remove their sutures, and discharge
The number of patients required for this trial was estimated on the them from the hospital. The timing of discharge was based on routine
basis of a preliminary study in which 80 patients undergoing elective surgical considerations, including the return of bowel function, the
colon surgery were randomly assigned to hypothermia (mean [SD] control of any infections, and adequate healing of the incision.
temperature, 34.40.4C) or normothermia (involving warming with
forced air and uid to a mean temperature of 370.3C). The number Measurements
of wound infections (as dened by the presence of pus and a positive The patients morphometric characteristics and smoking history
culture) was evaluated by an observer unaware of the patients tem- were recorded. The preoperative laboratory evaluation included a
peratures and group assignments. Nine infections occurred in the 38 complete blood count; determinations of the prothrombin time and
patients assigned to hypothermia, but there were only four in the 42 partial-thromboplastin time; measurements of serum albumin, total
patients assigned to normothermia (P  0.16). Using the observed dif- protein, and creatinine; and liver-function tests. The risk of infection
ference in the incidence of infection, we determined that an enroll- was scored with a standardized algorithm taken from the Study on the
ment of 400 patients would provide a 90 percent chance of identifying Efcacy of Nosocomial Infection Control (SENIC) of the Centers for
a difference with an alpha value of 0.01. We therefore planned to study Disease Control and Prevention; in this scoring system, one point
a maximum of 400 patients, with the results to be evaluated after 200 each is assigned for the presence of three or more diagnoses, surgery
and 300 patients had been studied. The prospective criterion for end- lasting two hours or more, surgery at an abdominal site, and the pres-
ing the study early was a difference in the incidence of surgical-wound ence of a contaminated or infected wound.2 The scoring system was
infection between the two groups with a P value of less than 0.01. To modied slightly from its original form by the use of the diagnoses
compensate for the two initial analyses, a P value of 0.03 would be made at admission, rather than discharge. The risk of infection was
required when the study of 400 patients was completed. The com- quantied further with the use of the National Nosocomial Infection
bined risk of a type I error was thus less than 5 percent.24 Surveillance System (NNISS), a scoring system in which the patients
risk of infection was predicted on the basis of the type of surgery, the
Study Protocol patients physical-status rating on a scale developed by the American
The night before surgery, each patient underwent a standard me- Society of Anesthesiologists, and the duration of surgery.3
chanical bowel preparation with an electrolyte solution. Intraluminal Core temperatures were measured at the tympanic membrane
antibiotics were not used, but treatment with cefamandole (2 g intra- (Mallinckrodt Anesthesiology Products, St. Louis), with values re-
venously every eight hours) and metronidazole (500 mg intravenously corded preoperatively, at 10-minute intervals intraoperatively, and at
every eight hours) was started during the induction of anesthesia; this 20-minute intervals for 6 hours during recovery. Arteriovenous-shunt
treatment was maintained for about four days postoperatively. Anes- ow was quantied by subtracting the skin temperature of the nger-
thesia was induced with thiopental sodium (3 to 5 mg per kilogram tip from that of the forearm, with values exceeding 0 C indicating
of body weight), fentanyl (1 to 3 mg per kilogram), and vecuronium thermoregulatory vasoconstriction.27 End-tidal concentrations of iso-
bromide (0.1 mg per kilogram). The administration of isourane (in urane and carbon dioxide were recorded at 10-minute intervals dur-
60 percent nitrous oxide) was titrated to maintain the mean arterial ing anesthesia. Measurements of arterial blood pressure and heart
blood pressure within 20 percent of the preinduction values. Addition- rate were recorded similarly during anesthesia and for six hours there-
al fentanyl was administered on the completion of surgery, to improve after. Oxyhemoglobin saturation was measured by pulse oximetry.
analgesia when the patient emerged from anesthesia. Thermal comfort was evaluated at 20-minute intervals for 6 hours
The patients were hydrated aggressively during and after surgery, postoperatively with a 100-mm visual-analogue scale on which 0 mm
because hypovolemia decreases wound perfusion and increases the in- denoted intense cold, 50 mm denoted thermal comfort, and 100 mm
cidence of infection.25,26 We administered 15 ml of crystalloid per kil- denoted intense warmth. The degree of surgical pain was evaluated
ogram per hour throughout surgery and replaced the volume of blood similarly, except that 0 mm denoted no pain and 100 mm the most
lost with either crystalloid in a 4:1 ratio or colloid in a 2:1 ratio. Fluids intense pain imaginable. Shivering was assessed qualitatively, on a
were administered intravenously at rates of 3.5 ml per kilogram per scale on which 0 denoted no shivering; 1, mild or intermittent shiver-
hour for the rst 24 postoperative hours and 2 ml per kilogram per ing; 2, moderate shivering; and 3, continuous, intense shivering. All

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Vol. 334 No. 19 PERIOPERATIVE NORMOTHERMIA TO REDUCE THE INCIDENCE OF WOUND INFECTION 1211

the qualitative assessments were made by observers unaware of the not were evenly distributed between the study groups
patients group assignments and core temperatures. and mostly returned to visit the private ofces of their
The patients surgical wounds were evaluated daily during hospital-
ization and again two weeks after surgery by a physician who was un- attending surgeons. The wound status of these patients
aware of the group assignments. Wounds were suspected of being in- was determined by calling the physician. No previously
fected when pus could be expressed from the surgical incision or unidentied wound infections were detected in the clin-
aspirated from a loculated mass inside the wound. Samples of pus ic for the rst time.
were obtained and cultured for aerobic and anaerobic bacteria, and
wounds were considered infected when the culture was positive for
Table 1 shows that the characteristics, diagnoses,
pathogenic bacteria. All the wound infections diagnosed within 15 types of surgical procedure, duration of surgery, hemo-
days of surgery were included in the data analysis. dynamic values, and types of anesthesia of the patients
Wound healing and infections were also evaluated by the ASEPSIS in the two study groups were similar. Nor did smoking
system,28 in which a score is calculated as the weighted sum of points status, the results of preoperative laboratory tests, or pre-
assigned to the following factors: the duration of antibiotic administra-
tion, the drainage of pus during local anesthesia, the dbridement of the operative laboratory values differ signicantly between
wound during general anesthesia, the presence of a serous discharge, the groups. The patients assigned to hypothermia re-
the presence of erythema, the presence of a purulent exudate, the sep- quired more transfusions of allogeneic blood (P  0.01).
aration of deep tissues, the isolation of bacteria from uid discharged Intraoperative vasoconstriction was observed in 74 per-
from the wound, and a duration of hospitalization exceeding 14 days.
Scores exceeding 20 on this scale indicate wound infection. As an addi-
cent of the patients assigned to hypothermia but in only
tional indicator of infection, preoperative differential white-cell counts
were compared with counts obtained on postoperative days 1, 3, and 6.
Collagen deposition in the wound was evaluated in a subgroup of Table 1. Characteristics of the Patients in the Two
30 patients in the normothermia group and 24 patients in the hypo- Study Groups.*
thermia group. A 10-cm expanded polytetrauoroethylene tube (Im-
pra, International Polymer Engineering, Tempe, Ariz.) was inserted NORMOTHERMIA HYPOTHERMIA P
CHARACTERISTIC (N  104) (N  96) VALUE
subcutaneously several centimeters lateral to the incision at the com-
pletion of surgery. On the seventh postoperative day, the tube was re- Male sex (no. of patients) 58 50 0.70
moved and assayed for hydroxyproline, a measure of collagen depo- Weight (kg) 7314 7114 0.31
sition.29 The ingrowth of collagen in such tubes is proportional to the
Height (cm) 1709 1699 0.43
tensile strength of the healing wound 29 and the subcutaneous oxygen
tension.22 Age (yr) 6115 5914 0.33
History of smoking (no. of patients) 33 29 0.94
Statistical Analysis Diagnosis (no. of patients)
Inammatory bowel disease 10 8 0.94
Outcomes were evaluated on an intention-to-treat basis. The num- Cancer 94 88
ber of postoperative wound infections in each study group and the Dukes stage 1.0
proportion of smokers among the infected patients were analyzed by A 29 30
Fishers exact test. Scores for wound healing, the number of days of B 37 34
hospitalization, the extent of collagen deposition, postoperative core C 26 21
D 2 3
temperatures, and potential confounding factors were evaluated by Operative site 0.61
unpaired, two-tailed t-tests. Factors that potentially contributed to in- Colon 59 51
fection were included in a univariate analysis. Those that correlated Rectum 35 37
signicantly with infection were then included in a multivariate logis- Preoperative variables
tic regression with backward elimination; a P value of less than 0.25 Core temperature ( C) 36.80.4 36.70.4 0.08
was required for a factor to be retained in the analysis. Hemoglobin (g/dl) 12.62.3 12.72.0 0.74
All the results are presented as means SD. A P value of less than Intraoperative variables
0.01 was required to indicate a signicant difference in our major out- Fentanyl administered (mg) 0.70.3 0.60.5 0.09
comes (the incidence of infection and the duration of hospitalization); End-tidal isourane (%) 0.60.1 0.60.2 1.0
a P value of less than 0.005 was considered to indicate a signicant Arterial blood pressure (mm Hg) 9117 9518 0.11
difference in postoperative temperature (to compensate for multiple Heart rate (beats/min) 7417 7613 0.35
comparisons); for all other data, a P value of less than 0.05 was con- Crystalloid (liters) 3.31.5 3.20.9 0.57
Colloid (liters) 0.20.3 0.20.3 1.0
sidered to indicate a statistically signicant difference. Red-cell transfusion (no. of patients) 23 34 0.054
Volume of blood transfused (units) 0.41.0 0.81.2 0.01
RESULTS Urine output (liters) 0.60.4 0.70.4 0.08
Duration of surgery (hr) 3.11.0 3.10.9 1.0
Patients were enrolled in the study from July 1993 Ambient temperature ( C) 21.91.2 22.10.9 0.19
through March 1995; 155 were evaluated at the Univer- Oxyhemoglobin saturation (%) 97.31.5 97.51.3 0.32
Final core temperature ( C) 36.60.5 34.70.6 0.001
sity of Vienna, 30 at the University of Graz, and 15 at
Postoperative variables
Rudolfstiftung Hospital. According to the investigation- Hemoglobin (g/dl) 11.71.9 11.61.4 0.67
al protocol, the study was stopped after 200 patients Prophylactic antibiotics (days) 3.71.9 3.61.4 0.67
were enrolled, because the incidence of surgical-wound SENIC score (no. of patients) 0.98
1 3 3
infection in the two study groups differed with an alpha 2 95 88
level of less than 0.01. One hundred four patients were 3 6 5
NNISS score (no. of patients) 0.6
assigned to the normothermia group, and 96 to the hy- 0 32 31
pothermia group. An audit conrmed that the patients 1 49 39
had been properly assigned to the groups and that the 2 23 26
Infection rate predicted by NNISS (%) 8.9 8.8
slight disparity in numbers was present in the original Oxyhemoglobin saturation (%) 981 981 1.0
computer-generated randomization codes. All the pa- Piritramide (mg) 2013 2212 0.26
tients allowed their wounds to be evaluated daily dur-
*Plusminus values are means SD. SENIC denotes Study on the Efcacy of Nosocomial
ing hospitalization. Ninety-four percent returned for Infection Control, and NNISS National Nosocomial Infection Surveillance System.
the two-week clinic visit after discharge; those who did The administration of this analgesic agent was controlled by the patient.

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1212 THE NEW ENGLAND JOURNAL OF MEDICINE May 9, 1996

6 percent of those assigned to normothermia (P0.001). ceeded 20 in 32 percent of the former but only 6 per-
Core temperatures at the end of surgery were signicant- cent of the latter (P0.001).
ly lower in the hypothermia group than in the normo- In a univariate analysis, tobacco use, group assign-
thermia group (34.70.6 vs. 36.60.5C, P0.001), and ment, surgical site, NNISS score, SENIC score, need for
they remained signicantly different for more than ve transfusion, and age were all correlated with the risk of
hours postoperatively (Fig. 1). infection. In a multivariate backward-elimination anal-
Postoperative vasoconstriction was observed in 78 ysis, tobacco use, group assignment, surgical site, NNISS
percent of the patients in the hypothermia group; the score, and age remained risk factors for infection (Ta-
vasoconstriction continued throughout the six-hour re- ble 3).
covery period. In contrast, vasoconstriction, usually Four patients in the normothermia group and seven
short-lived, was observed in only 22 percent of the pa- in the hypothermia group required admission to the in-
tients in the normothermia group (P0.001). Shivering tensive care unit (P0.47), mainly because of wound
was observed in 59 percent of the hypothermia group, dehiscence, colon perforation, and peritonitis. Two pa-
but in only a few patients in the normothermia group. tients in each group died during the month after sur-
Thermal comfort was signicantly greater in the nor- gery. The incidence of infection was similar at each study
mothermia group than in the hypothermia group (score hospital, and no one surgeon was associated with a dis-
on the visual-analogue scale one hour after surgery, proportionate number of infections.
7314 vs. 3517 mm). The difference in thermal com- Table 2 shows that signicantly more collagen was
fort remained statistically signicant for three hours. deposited near the wound in the patients in the normo-
Pain scores and the amount of opioid administered were thermia group than in the patients in the hypothermia
virtually identical in the two groups at every postop- group (328135 vs. 254114 mg per centimeter). The
erative measurement; hemodynamic values were also patients assigned to hypothermia were rst able to tol-
similar. erate solid food one day later than those assigned to
The overall incidence of surgical-wound infection normothermia (P0.006); similarly, the sutures were
was 12 percent. Although the SENIC and NNISS scores removed one day later in the patients assigned to hy-
for the risk of infection were similar in the two groups, pothermia (P0.002). The duration of hospitalization
there were only 6 surgical-wound infections in the nor- was 12.14.4 days in the normothermia group and
mothermia group, as compared with 18 in the hypo- 14.76.5 days in the hypothermia group (P0.001).
thermia group (P0.009) (Table 2). Most positive cul- This difference was statistically signicant even when
tures contained several different organisms; the major the analysis was limited to the uninfected patients. In
ones were E. coli (11 cultures), S. aureus (7), pseudomo- the normothermia group, the duration of hospitaliza-
nas (4), enterobacter (3), and candida (3). Culture-neg- tion was 11.84.1 days in patients without infection and
ative pus was expressed from the wounds of two pa- 17.37.3 days in patients with infection (P0.003). In
tients assigned to hypothermia and one patient assigned the hypothermia group the duration of hospitalization
to normothermia. The ASEPSIS scores were higher in was 13.54.5 days in patients without infection and
the hypothermia group than in the normothermia group 20.711.6 days in patients with infection (P0.001).
(1316 vs. 710, P0.002) (Table 2); these scores ex- The postoperative hemoglobin concentrations did not
differ signicantly between the two
groups (Table 1). On the rst post-
Intraoperative Postoperative
operative day, leukocytosis was im-
38 paired in the hypothermia group
Core Temperature (C)

Normothermia as compared with the normothermia


37
group (white-cell count, 11,5003500
vs. 13,4002500 cells per cubic mil-
36
limeter; P0.001). On the third post-
Hypothermia operative day, however, white-cell
35
counts were signicantly higher in
the hypothermia group (10,1003900
vs. 89002900 cells per cubic milli-
34
0 1 2 3 Final 0 1 2 3 4 5 6 meter). The difference in values on
the third day was not statistically sig-
Time (hr) nicant when only uninfected pa-
Figure 1. Core Temperatures during and after Colorectal Surgery in the Study tients were included in the analysis.
Patients. By the sixth postoperative day, the
The mean (SD) nal intraoperative core temperature was 34.70.6C in the white-cell counts were similar in the
96 patients assigned to hypothermia, who received routine thermal care, and two groups.
36.60.5C in the 104 patients assigned to normothermia, who were given extra
warming. The core temperatures in the two groups differed signicantly at each
Among smokers, the number of
measurement, except before the induction of anesthesia (rst measurement) and af- cigarettes smoked per day was similar
ter six hours of recovery. in the two groups (2220 in the hy-

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Vol. 334 No. 19 PERIOPERATIVE NORMOTHERMIA TO REDUCE THE INCIDENCE OF WOUND INFECTION 1213

Table 2. Postoperative Findings in the Two minor clinical importance. The hospitalizations of infect-
Study Groups.* ed patients were one week longer than those of patients
without surgical-wound infections, however, indicating
NORMOTHERMIA HYPOTHERMIA
VARIABLE (N  104) (N  96) P VALUE that most infections were substantial. Similar prolonga-
tion of hospitalization has been reported previously.1,2
All patients
It is interesting to note that hospitalization was also
Infection no. of 6 (6) 18 (19) 0.009
patients (%) prolonged (by about two days) in the uninfected pa-
ASEPSIS score 710 1316 0.002 tients in the hypothermia group (Table 2). A number of
Collagen deposition 328135 254114 0.04 factors inuenced the decision to discharge patients,
mg/cm
Days to rst solid food 5.62.5 6.52.0 0.006 but healing of the incision (formation of a healing
Days to suture removal 9.82.9 10.91.9 0.002 ridge, for example) was among the most important.
Days of hospitalization 12.14.4 14.76.5 0.001
As is consistent with a delay in clinical healing, sutures
Uninfected patients were removed signicantly later and the deposition of
No. of patients 98 78
Days to rst solid food 5.21.6 6.11.6 0.001
collagen (an index of scar formation and the strength
Days to suture removal 9.62.6 10.61.6 0.003 of the healing wound) was signicantly less in the
Days of hospitalization 11.84.1 13.54.5 0.01 hypothermia group than in the normothermia group.
*Plusminus values are means SD.
That the patients assigned to hypothermia required sig-
nicantly more time before they could tolerate solid
food is also consistent with impaired healing.
pothermia group vs. 2214 in the normothermia group). In Austrias medical system, administrative factors
The morphometric characteristics, anesthetic care, and and costs of hospitalization do not inuence the length
SENIC and NNISS scores of smokers and nonsmokers of stay in the hospital. No data on individual costs are
were not signicantly different. Nonetheless, the propor- tabulated by the participating hospitals, and they are
tion of patients with wound infection was signicantly therefore not available for our patients. Nonetheless,
higher among smokers (23 percent, or 14 of 62) than the cost of a prolonged hospitalization must exceed the
among nonsmokers (7 percent, or 10 of 138; P0.004). cost of uid and forced-air warming (approximately
Furthermore, the length of hospitalization was signif- $30 in the United States). In a managed-care situation,
icantly greater among smokers (14.96.7 days, vs. the duration of hospitalization might have differed less,
12.95.0 days among nonsmokers; P0.02) (Table 4). or not at all. However, our data suggest that patients
kept at normal temperatures during surgery would be
DISCUSSION better prepared for discharge at a xed time than those
The initial hours after bacterial contamination are a allowed to become hypothermic.
decisive period for the establishment of infection.25 In Among all 200 patients in our study, those who
surgical patients, perioperative factors can contribute smoked had three times more surgical-wound infections
to surgical-wound infections, but the infection itself is and signicantly longer hospitalizations than the non-
usually not manifest until days later. smokers. Similar data have been reported previously.32
In our study, forced-air warming combined with uid Numerous factors contributed to these results; one may
warming maintained normothermia in the treated pa- have been that smoking markedly lowers oxygen tension
tients, whereas the unwarmed patients had core temper- in tissue for nearly an hour after each cigarette.33 (Ther-
atures approximately 2C below normal.8 Perioperative moregulatory vasoconstriction produces a similar reduc-
hypothermia persisted for more than four hours and tion.34) The distribution of factors known to inuence in-
thus included the decisive period for establishing an in- fection was similar between smokers and nonsmokers,
fection.25,30 The patients with mild perioperative hypo- but the smokers may have had other behavioral or phys-
thermia had three times as many culture-positive sur- iologic factors predisposing them to infection.
gical-wound infections as the normothermic patients. The prevalence of smoking was similar in the two
Moreover, the ASEPSIS scores showed that in the pa-
tients assigned to hypothermia the reduction in resist-
Table 3. Multivariate Analysis of Risk Fac-
ance to infection was twice that in the normothermia tors for Surgical-Wound Infection.
group.
The types of bacteria cultured from our patients sur- ODDS RATIO
(95% CONFIDENCE
gical wounds were similar to those reported previously.2,3 RISK FACTOR INTERVAL)
These organisms are susceptible to oxidative killing,
Tobacco use (yes vs. no) 10.5 (3.234.1)
which is consistent with our hypothesis that hypothermia Group assignment (hypothermia vs. 4.9 (1.714.5)
inhibits the oxidative killing of bacteria.31 The overall in- normothermia)
cidence of infection in our study was approximately 35 Surgical site (rectum vs. colon) 2.7 (0.97.6)
percent higher than in previous reports.3 One explana- NNISS score (per unit increase)* 2.5 (1.25.3)
tion for this relatively high incidence is that we consid- Age (per decade) 1.6 (1.02.4)
ered all wounds draining pus that yielded a positive cul- *NNISS denotes National Nosocomial Infection Surveillance
ture to be infected, although some may have been of System.

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1214 THE NEW ENGLAND JOURNAL OF MEDICINE May 9, 1996

Table 4. Postoperative Findings in the Study Pa- We are indebted to Heinz Scheuenstahl for the collagen-deposition
tients According to Smoking Status.* analysis; to Helene Ortmann, M.D., Andrea Hubacek, M.D., Michael
Zimpfer, M.D., and Gerhard Pavecic for their generous assistance;
SMOKERS NONSMOKERS P and to Mallinckrodt Anesthesiology Products, Inc., for the donation
VARIABLE (N  62) (N  138) VALUE of thermometers and thermocouples.
Infection no. of patients (%) 14 (23) 10 (7) 0.004 APPENDIX
ASEPSIS score 1518 810 0.001
The following investigators also participated in this study: patient
Days to suture removal 10.93.5 10.12.0 0.04
safety and data auditing: H.W. Hopf and T.K. Hunt (University of
Days of hospitalization 14.96.7 12.95.0 0.02 California, San Francisco); site directors: G. Polak (Hospital Ru-
SENIC score 0.25 dolfstiftung, Vienna, Austria) and W. Krll (University of Graz, Graz,
1 0 6 Austria); patient care: F. Lackner and R. Fuegger (University of Vi-
2 58 125
enna); data acquisition: E. Narzt (University of Vienna), C. Wolrab
3 4 7
(University of Vienna), E. Marker (University of Vienna), A. Bekar
NNISS score 0.08
(Orthopedic Hospital, Speising, Vienna), H. Kaloud (University of
0 23 40
1 30 58 Graz), U. Stratil (Hospital Rudolfstiftung), and R. Csepan (Universi-
2 9 40 ty of Vienna); wound evaluation: V. Goll (University of Vienna),
G.S. Bayer (University of Vienna), and P. Steindorfer (University of
*Plusminus values are means SD. SENIC denotes Study on the Ef- Graz); and data management: B. Petschnigg (University of Vienna).
cacy of Nosocomial Infection Control, and NNISS National Nosocomial
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Vol. 334 No. 19 PERIOPERATIVE NORMOTHERMIA TO REDUCE THE INCIDENCE OF WOUND INFECTION 1215

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