Circulation Skills 7:
Rewarming Techniques
Warm Thoracic Lavage
Warm thoracic lavage is an effective method of rewarming severely hypothermic patients. It is more invasive than heated humidified ventilation, gastric lavage, urinary bladder lavage, and closed peritoneal lavage. However, warm thoracic lavage may be initiated when the clinical and logistical situation is such that more rapid rewarming is needed.
- Insert a chest tube in the left chest and direct as usual, posteriorly and superiorly. A size 36 chest tube would be appropriate for an adult. PEDS: See Vol II—Breath Skills 1 Chest Tube Insertion, Vol II—Breath Skills 2 Chest Suction and Autotransfusion for technical guidance. Be sure to make a snug closure around the chest tube so that fluid does not pour out. Attach the chest tube to chest suction using an autotransfusion attachment.
- While the lung is down during placement of the chest tube, perform a needle thoracostomy as described in Vol II—Breath Skills 5 Needle Thoracostomy.
- Perform lavage by hanging warm bags of saline (104ºF) and running them into the chest through the needle thoracostomy. The saline should return out of the chest through the chest tube. Collect this saline in the autotransfusion bag for easy emptying when full. It may help to turn the patient toward the right to ensure that the heart is bathed in warm saline. A rapid fluid warmer/infusor may be used to speed delivery of the warm saline into the chest. Maintain positive pressure ventilation to assure that the lungs remain inflated.
Continue rewarming in this way until core temperature reaches 86ºF and external warmth can be applied.
Reference
Winegard C. Successful treatment of severe hypothermia and prolonged cardiac arrest with closed thoracic lavage. J Emerg Med. 1997;15(5):629-632.
Warm Peritoneal Lavage in Hypothermia
Peritoneal lavage can be an effective method of core rewarming in a rural hospital. If a patient does not have a surgical scar on the abdomen, a closed technique for cannula insertion may be used. If there is a surgical scar, bowel adhesions may be present, and an open technique is necessary. Other indications for an open technique are pregnancy, obesity, and presence of pelvic fracture. The open technique requires the surgical skills of a physician experienced with opening the abdomen. Only the closed technique is described here. Before proceeding, empty the stomach with an orogastric tube, and drain the urinary bladder with a Foley catheter.
Closed technique: A safe technique for inserting the lavage cannula into the abdominal cavity in an obtunded hypothermic patient follows:
- Place 2 towel clips separated by 1 or 2 inches into the abdominal wall in the midline just below the umbilicus.
- Use an Arrow Peritoneal Lavage Kit. Attach a 5 mL syringe of saline to the 18-gauge exploring needle. Fill the needle with saline and leave the syringe attached.
- Pinch the skin and subcutaneous tissue between the 2 towel clips, and insert the needle into the subcutaneous tissue. Remove the syringe and add another drop of saline to the hub of the needle.
- Have an assistant lift the abdominal wall with the towel clips, producing negative pressure in the abdominal cavity.
- Advance the needle through the fascia of the abdominal wall until the saline filling the needle is suddenly sucked into the abdominal cavity when the peritoneum is penetrated.
- Insert the J tip of the guidewire through the exploring needle and into the abdominal cavity. Before removing the needle, make a stab wound with a #11 scalpel blade through the fascia, keeping the point of the blade in contact with the needle. Remove the needle. Keep the blue or purple plastic piece used to straighten the J wire sterile. It may be used later as a dilator.
- Pass the 8 French lavage catheter over the wire into the abdomen. Attach the enclosed fluid administration set to a bag of warm saline (104ºF) and flush it prior to connecting it to the lavage catheter. If the catheter meets resistance at the belly wall, use the blue or purple plastic piece from the guidewire as a dilator to increase the size of the opening.
- Run in the warm saline “wide open.” Let it exchange heat with the body
for 1 to 2 minutes, then drain it out by placing the empty bag on the
floor. Repeat until the patient's core temperature approaches 86ºF, at
which time external warmth may be applied. Use the tubing supplied in
the kit because the needle-less system tubing has a one-way valve that
prevents drainage through it.
A peritoneal lavage tray
References
Vella J, Farrell J, Leavey S, Magee C, et al. The rapid reversal of profound hypothermia using peritoneal dialysis. Ir J Med Sci. 1996;165(2):113-114.
Visetti E, Pastorelli M, Bruno M. Severe accidental hypothermia successfully treated by warmed peritoneal lavage. Minerva Anestesiol. 1998;64(10):471-475.