How should postoperative warming be managed in a patient after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) to prevent hypothermia?

Postoperative Warming After HIPEC

Active warming devices (forced-air warming blankets and warmed intravenous fluids) should be applied immediately upon arrival to the ICU and continued until core temperature is maintained above 36°C, with continuous core temperature monitoring (esophageal, bladder, or rectal) to prevent rebound hypothermia—a specific and dangerous complication after HIPEC.

Understanding the Unique Risk: Rebound Hypothermia After HIPEC

Post-HIPEC patients face a paradoxical temperature challenge distinct from standard surgery:

• Rebound hypothermia occurs in the immediate postoperative period despite intraoperative hyperthermia, and has been associated with cardiac arrest in multiple case reports 1
• The incidence of hypothermia on ICU arrival is 57.8% in general postoperative patients, but HIPEC patients face additional risk from massive fluid shifts (median 8.4 liters), prolonged surgery (median 715 minutes), and significant blood loss 2, 3
• Core temperature typically decreases 1.6°C in the first hour after anesthesia, with 81% of this decrease due to redistribution 2

Immediate Postoperative Warming Protocol

Core Temperature Monitoring (Mandatory)

• Continuous core temperature monitoring (bladder, esophageal, or rectal) is strongly recommended over superficial measurements (skin, tympanic) for major surgery 4
• Temperature should be documented continuously, not intermittently, as hypothermia is poorly recognized in 62% of trauma admissions 2
• Target: maintain core temperature >36°C 5

Active Warming Interventions

Primary warming methods (apply simultaneously):

• Forced-air warming blankets: Most effective active warming device for postoperative patients 2, 4, 5
• Warmed intravenous fluids: All IV fluids should be administered through fluid warming devices 2, 4, 5
• Increase ambient temperature: ICU room temperature should be maintained at 21-25°C 4

Fluid Management Considerations

• Avoid cold fluid administration, as this is an independent risk factor for postoperative hypothermia 2, 3
• Be aware that HIPEC patients receive massive fluid volumes (median 8.4 liters intraoperatively), making warmed fluid administration critical 3
• Balanced crystalloid solutions are preferred over 0.9% sodium chloride 2

Critical Pitfalls to Avoid

The Rebound Hypothermia Phenomenon

• Do not assume normothermia based on intraoperative hyperthermia during HIPEC (41-43°C perfusate temperature) 6, 7
• Rebound hypothermia can occur rapidly despite active intraoperative cooling measures 1, 8
• This complication has been associated with cardiac arrest when combined with hypokalemia and metabolic derangements 1

Metabolic Monitoring

• Monitor potassium levels closely, as hypokalemia combined with hypothermia increases cardiac arrest risk 1
• Hypothermia decreases insulin sensitivity and secretion, causing hyperglycemia 4

Consequences of Inadequate Warming

• Hypothermia <34°C carries >80% independent mortality risk after controlling for other factors 4
• Even mild hypothermia increases blood loss by 16% and transfusion risk by 22% 2, 4
• Hypothermia profoundly impairs platelet function (33-37°C) and coagulation factor activity (<33°C) 4

Duration of Active Warming

• Continue active warming measures until core temperature is stably maintained above 36°C without assistance 5
• Given the median hospital stay of 8-24 days post-HIPEC, temperature monitoring should extend beyond the immediate postoperative period 7
• Independent risk factors for persistent hypothermia include surgery duration >3 hours, general anesthesia, and cold fluid administration—all present in HIPEC procedures 2

Special Considerations for HIPEC Patients

• The combination of massive blood loss (median 0.8 liters), large fluid shifts, prolonged operative time, and metabolic disturbances makes HIPEC patients particularly vulnerable 3
• Warming devices and higher early temperatures are protective factors against postoperative hypothermia 2
• Remove any wet surgical drapes or clothing immediately, as this contributes to ongoing heat loss 4