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Dlaczego okołooperacyjna hipotermia zwiększa ryzyko zakażenia miejsca operowanego?

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Pooperacyjne powikłania infekcyjne w znaczącym stopniu utrudniają i wydłużają rekonwalescencję pacjenta i mogą stanowić przyczynę zgonu. Jedną z możliwych przyczyn wystąpienia powikłań są zaburzenia termoregulacji w okresie okołooperacyjnym.

Obniżenie temperatury centralnej w organizmie operowanego pacjenta poniżej 36 st. C określa się jako niezamierzoną śródoperacyjną hipotermię. Może ona mieć znaczący wpływ na przebieg zabiegu chirurgicznego i długość rekonwalescencji, a także powodować wystąpienie powikłań.

Powikłania hipotermii śródoperacyjnej

Wśród możliwych następstw niezamierzonej śródoperacyjnej hipotermii wymienia się: wydłużenie działania anestetyków dożylnych i leków zwiotczających mięśnie poprzecznie prążkowane, zaburzenia krzepnięcia i znaczący wzrost krwawienia okołooperacyjnego, wzrost ryzyka incydentów wieńcowych i częstoskurczu komorowego po operacji, a także nawet trzykrotny wzrost ryzyka zakażenia miejsca operowanego.

Hipotermia a ryzyko powikłań infekcyjnych

W literaturze naukowej wskazuje się na wyraźny związek pomiędzy obniżeniem temperatury ciała a zwiększonym ryzykiem wystąpienia zakażenia miejsca operowanego. Przyczyn tej korelacji upatruje się w dwóch mechanizmach związanych ze zmianami temperatury ustroju w wyniku znieczulenia. Mechanizmy te to zmniejszenie ukrwienia okolicy rany operacyjnej oraz wystąpienie zaburzeń immunologicznych.

Wychładzanie organizmu skutkuje wystąpieniem wazokonstrykcji, czyli zmniejszeniem ukrwienia skóry w reakcji na nadmierną utratę ciepła. Ograniczenie dopływu krwi wpływa na zmniejszenie dostarczania tlenu do tkanek w okolicy miejsca operowanego zarówno podczas zabiegu, jak i po jego zakończeniu. Zmniejszony dopływ tlenu do tkanek wpływa na upośledzenie podstawowych mechanizmów immunologicznych. Ma to związek z tym, że zdolność białych krwinek do efektywnego niszczenia patogenów jest zależna od oksydacji. Z tego powodu występuje następująca zależność: im niższa temperatura organizmu, tym mniejsza skuteczność mechanizmów immunologicznych.

Hipotermia śródoperacyjna w wytycznych do opieki okołooperacyjnej

Problem niezamierzonej hipotermii śródoperacyjnej i związanych z nią powikłań pojawia się w wytycznych dotyczących opieki okołooperacyjnej. Najbardziej szczegółowo kwestia ta jest omawiana w wytycznych brytyjskiego ośrodka National Institute of Clinical Excellence (NICE).

W wytycznych NICE uwzględniono kryteria ryzyka hipotermii śródoperacyjnej z uwzględnieniem indywidualnych cech chorego, rodzaju operacji i czasu jej trwania, a także stosowanego znieczulenia. Autorzy wytycznych zwracają uwagę zarówno na konieczność monitorowania temperatury pacjenta podczas operacji, jak i stosowania odpowiednich metod zapobiegania hipotermii. Zgodnie z zaleceniami aktywne metody utrzymania normotermii powinno się stosować przy każdym zabiegu trwającym powyżej 30 minut, a także w każdym przypadku, kiedy zachodzi zwiększone ryzyko hipotermii (każda procedura wykonywana w znieczuleniu ogólnym w połączeniu ze znieczuleniem przewodowym).

Źródła:

1. Horosz, M. Malec-Milewska, „Hipotermia okołooperacyjna – czynnik zwiększający ryzyko powikłań infekcyjnych”, „Forum Zakażeń” 2014, 5(2): 67-71.

2. Horosz, M. Malec-Milewska, „Zwiększone ryzyko powikłań infekcyjnych jako skutek okołooperacyjnej hipotermii”, „Forum Zakażeń” 2015, 6(4): 227-230.

3. Adamiec, H. Misiołek, „Niezamierzona hipotermia okołooperacyjna a zakażenie miejsca operowanego”, „Forum Zakażeń” 2014, 5(6): 349-353.

 

Przeczytaj także: Przyczyny krwawienia do światła przewodu pokarmowego

Przeczytaj bezpłatnie pokrewny artykuł w czasopiśmie „Pielęgniarstwo w Anestezjologii i Intensywnej Opiece”:

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