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The Effects of Intraoperative Hypothermia

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ORIGINAL ARTICLE

The Effects of Intraoperative Hypothermia on Surgical

Site Infection
An Analysis of 524 Trauma Laparotomies
Mark J. Seamon, MD, Jessica Wobb, BS, John P. Gaughan, PhD, Heather Kulp, MPH, Ihab Kamel, MD,
and Daniel T. Dempsey, MD

he Centers for Disease Control and Prevention (CDC) have estimated that nearly 30 million surgical procedures are performed
in the United States each year.1 Despite growing concern over quality improvement and limited reimbursement for hospital-acquired
complications, surgical site infections (SSI) remain a major health
problem. On the basis of data collected since 1970 in the National

Nosocomial Infections Surveillance system, the CDC has reported

that SSI comprise 38% of all nosocomial infections, making it the
most common such infection in surgical patients.1 Moreover, patients
who develop SSI are more likely to require intensive care unit admission, hospital readmission, and extended hospital length of stay, while
sustaining greater hospital charges and postoperative mortality.28
In an attempt to improve surgical outcomes, the CDC and Centers for Medicare and Medicaid developed the Surgical Care Improvement Project (SCIP) initiative to provide performance measures for
the most common surgical complications, including SSI. The 6 quality performance measures pertaining to SSI include (1) prophylactic
antibiotic administration within 60 minutes prior to skin incision, (2)
adherence to current prophylactic antibiotic regimen recommendations, (3) discontinuation of prophylactic antibiotics within 24 hours
postoperatively, (4) maintenance of perioperative normoglycemia in
cardiac surgery patients, (5) appropriate hair removal at the surgical site before incision, and (6) maintenance of normothermia in
patients undergoing colorectal procedures.912 Although these measures have been proven to reduce the incidence of SSI after elective
procedures,1117 data regarding the beneficial effects of these performance objectives for operative trauma procedures are more limited.
Scientific evidence limitations aside, patients requiring emergency trauma procedures are often at a greater risk for SSI than those
undergoing elective surgery. Patients with abdominal injuries undergoing laparotomy are commonly hypothermic and coagulopathic,
have ongoing hemorrhage and blood transfusion requirements, and
have gross enteric or fecal contamination. Previous reports have described a 9% to 32% SSI rate after trauma laparotomy and have
identified several risk factors important to the development of SSI
increasing patient age, hollow viscous organ injury, severe injury,
hemorrhagic shock, and blood transfusion.1828
Although intraoperative normothermia is an important quality performance measure for patients undergoing colorectal surgery,
the effects of intraoperative hypothermia on SSI remain unstudied
in trauma patients. Our primary study objective was to determine
whether intraoperative hypothermia predisposes patients undergoing
trauma laparotomy to postoperative SSI. Secondarily, we sought to
identify, through a cut-point analysis, which intraoperative nadir
temperature value is most predictive of SSI development and to determine the impact SSI has on outcomes in our trauma population.

From the Division of Trauma and Surgical Critical Care, Department of

Surgery, Cooper University Hospital, Camden, NJ, Department of Surgery,
Biostatistics Consulting Center; and Department of Anesthesia, Temple University School of Medicine, Philadelphia, PA.
Disclosure: The authors declare no conflicts of interest.
Reprints: Mark J. Seamon, MD, Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Ste 411, Camden, NJ 08103. E-mail: seamon-mark@
cooperhealth.edu.
C 2012 by Lippincott Williams & Wilkins
Copyright 
ISSN: 0003-4932/12/25504-0789
DOI: 10.1097/SLA.0b013e31824b7e35

After institutional review board approval was granted, a retrospective analysis of all trauma patients who underwent urgent laparotomy during July 2003 until July 2008 at Temple University Hospital
was performed. All patients between 18 and 88 years of age who
underwent trauma laparotomy, regardless of injury mechanism, were
eligible. Patients were excluded from study analysis for the following
criteria: injury greater than 2 hours before emergency department
arrival, preoperative temperature less than 35 C, laparotomy beyond
2 hours after emergency department arrival, or death within 4 days

Objectives: Our primary study objective was to determine whether intraoperative hypothermia predisposes patients to postoperative surgical site infections
(SSI) after trauma laparotomy.
Background: Although intraoperative normothermia is an important quality
performance measure for patients undergoing colorectal surgery, the effects
of intraoperative hypothermia on SSI remain unstudied in trauma.
Methods: A review of all patients (July 2003June 2008) who survived 4 days
or more after urgent trauma laparotomy at a level I trauma center revealed
524 patients. Patient characteristics, along with preoperative and intraoperative care focusing on SSI risk factors, including the depth and duration of
intraoperative hypothermia, were evaluated. The primary outcome measure
was the diagnosis of SSI within 30 days of surgery. Cut-point analysis of the
entire range of lowest intraoperative temperature measurements established
the temperature nadir that best predicted SSI development. Single and multiple
variable logistic regression determined SSI predictors.
Results: The mean intraoperative temperature nadir of the study population
(n = 524) was 35.2 C 1.1 C and 30.5% had at least 1 temperature measurement less than 35 C. Patients who developed SSI (36.1%) had a lower mean
intraoperative temperature nadir (P = 0.009) and had a greater number of
intraoperative temperature measurements <35 C (P < 0.001) than those who
did not. Cut-point analysis revealed an intraoperative temperature of 35 C as
the nadir temperature most predictive of SSI development. Multivariate analysis determined that a single intraoperative temperature measurement less than
35 C independently increased the site infection risk 221% per degree below
35 C (OR: 2.21; 95% CI: 1.243.92, P = 0.007).
Conclusions: Just as intraoperative hypothermia is an SSI risk factor in patients undergoing elective colorectal procedures, intraoperative hypothermia
less than 35 C adversely affects SSI rates after trauma laparotomy. Our results suggest that intraoperative normothermia should be strictly maintained
in patients undergoing operative trauma procedures.
(Ann Surg 2012;255:789795)

METHODS

Annals of Surgery r Volume 255, Number 4, April 2012

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Annals of Surgery r Volume 255, Number 4, April 2012

Seamon et al

of laparotomy. A total of 9503 patients were admitted by the trauma

service during the study period, of whom 640 underwent laparotomy.
One hundred sixteen patients were excluded because of the criteria
mentioned previously, resulting in a final study population of 524
patients.
Patient characteristics, including Injury Severity Scores and
Penetrating Abdominal Trauma Indices, were assessed. Preoperative
and intraoperative care focusing on SSI risk factors, including the
depth and duration of intraoperative hypothermia, were evaluated.
Intraoperative temperatures were measured by esophageal monitors
(Smith Medical ASD Inc, Rockland, MA) and recorded by anesthesia
at 5-minute intervals. All study patients received standard measures to
prevent intraoperative hypothermia. Patients were positioned supine
atop warm-water blankets and room temperatures were maintained
above 26 C. Warm forced dry air devices (Bair Hugger; Arizant Inc,
Eden Prairie, MN) were applied to unprepped areas of the upper or
lower extremities. Intravenous fluids and blood products were warmed
(Ranger; Arizant Inc, Eden Prairie, MN) and infused in high-flow
tubing (Hospira Inc, Lake Forest, IL).
Operative time was defined as the duration of time elapsed
between patient arrival into the operating department until patient
transport from the operating department. Although choice of preincisional antibiotics was under the discretion of the attending trauma
surgeon, intravenous cefazolin (1 gm) and metronidazole (500 mg)
or mefoxin (2 gm) were most commonly utilized. Patients with documented penicillin allergies were given intravenous ciprofloxacin
(400 mg) in lieu of cephalosporins. Antibiotics completed within 1
hour prior to surgical incision were defined as preincisional. Correct
antibiotic choice was defined as an antibiotic agent or agents covering
all injuries discovered during trauma laparotomy (eg, cefazolin and
flagyl, mefoxin, or ciprofloxacin and flagyl for patients with enteric
injuries).
SSI was defined by any of the following clinical criteria: documentation by an attending trauma surgeon indicating the presence
of an SSI, the institution of antibiotics specifically for a surgical site,
and the opening or packing of a surgical wound based on its appearance. Site infections were further classified by CDC criteria into
superficial incisional, deep incisional, or organ/space SSI.1 Superficial incisional SSI involved only the skin or subcutaneous tissues,
whereas deep incisional SSI involved the deep soft tissues of the
incision. Organ/space infections involved any location beyond the
incision that was manipulated during surgery.
The primary outcome measure was the diagnosis of SSI within
30 days of surgery. Categorical variables were analyzed using Fisher
exact test, whereas continuous variables were evaluated with Student
t test. Means are accompanied by standard deviations. Single and
multiple variable logistic regression analyses were used to determine
predictors of the primary study endpoint, the development of SSI. Significant predictors of SSI from univariate analysis were included in
the standard multiple logistic regression model to determine independent or adjusted predictors of SSI. Confounding variables controlled
for in the multiple logistic regression included body mass index, red
blood cell transfusion, the presence of enteric injuries, and operative
duration. P 0.05 was considered statistically significant.
The primary study objective was to determine whether intraoperative hypothermia predisposes patients to postoperative SSI after
trauma laparotomy. To this end, a cut-point analysis of the entire
range of lowest intraoperative temperature measurements was performed to establish the exact temperature nadir that best predicted
the development of an SSI. Locally weighted regression was used
to determine inflection points in the relationship between lowest intraoperative temperature and SSI development based on the Pearson
residuals. From observed inflection points in this temperatureSSI
relationship, several cut points for the lowest intraoperative tempera790 | www.annalsofsurgery.com

ture were chosen. These were substituted into the multivariate model
and tested for the best fit based on 2 Log likelihood values.
Single and multiple variable regression analysis were also used
to evaluate the impact of SSI on secondary clinical outcome parameters including antibiotic duration, postoperative complications, and
length of stay. Other infectious complications evaluated included the
development of pneumonia, bacteremia, and urinary tract infection.
Ventilator dependent respiratory failure, defined by mechanical ventilation greater than 48 hours, and acute renal failure, defined by
increase in serum creatinine greater than 50% of baseline, were also
assessed. All data were analyzed using SAS V9.1 (SAS Institute,
Cary, NC).

RESULTS

The study population (n = 524) consisted primarily of young

(mean age: 30.9 12.4 years) men (89.7%) who sustained gunshot
wounds (64.2%) or stab wounds (21.0%). Preincisional antibiotics
were administered to 93.1% of patients and 85.9% received the antibiotics within 60 minutes of surgical incision. While 22.5% had
at least 1 intraoperative systolic blood pressure measurement below
90 mm Hg, 37.2% had intraoperative blood transfusions and 45.8%
had enteric injuries. The mean intraoperative temperature nadir was
35.2 C 1.1 C, and 30.5% had at least 1 temperature measurement
less than 35 C. Overall, 36.1% developed an SSI (superficial incisional, 17.6%; deep incisional, 0.6%; organ/space, 15.8%; both incisional and organ/space, 2.1%) that was diagnosed either during their
hospitalization (31.1%) or outpatient follow-up (5.0%). The mean
postoperative time until SSI diagnosis was 8.6 5.4 days. Despite
prolonged intensive care unit (7.3 14.8 days) and hospital (17.2
24.8 days) length of stay, 97.1% survived their hospitalization.
Patients who developed SSI (n = 189) were compared with
those who did not (n = 335, Table 1). Patients who developed SSI
were more often injured by gunshot and had greater Injury Severity
Scores and Penetrating Abdominal Trauma Indices scores. Although
hypotension, blood transfusion, and enteric injury were more common in the SSI group, preincisional antibiotics were less often utilized
in those who developed SSI. In those who received preincisional antibiotics, no difference in correct antibiotic administration (agent and
dose) was noted between groups (P > 0.05), although prophylactic antibiotics were continued longer in patients who developed SSI
(9.8 17.7 days) than those who did not (3.1 3.7 days, P < 0.001).
Despite more commonly undergoing damage control closures, those
who formed site infections had longer operative times than those
without site infections. Patients who developed SSI had a lower mean
intraoperative temperature nadir (35.0 C 1.1 C vs 35.4 C 1.0 C,
P = 0.009) and had a greater number of intraoperative temperature
measurements below 35 C (2.9 5.0 vs 1.2 2.8, P < 0.001) than
those who did not develop SSI.
Potential SSI risk factors, including intraoperative temperature
nadir, were analyzed. To determine which intraoperative temperature
nadir value best predicted the development of SSI after trauma laparotomy, a cut-point analysis of the entire range of lowest intraoperative
temperature measurements was performed (Fig 1 1A, B). When several nadir measurements were tested, an intraoperative temperature
of 35 C proved to be the cut-point temperature with the best model
fit and thus was most predictive of SSI development. After this cutpoint value was established, patients were compared on the basis of
lowest intraoperative temperature measurement and categorized by
this cut-point value (<35 C vs 35 C) in Figure 2. Increased SSI
rates in the intraoperative temperature nadir less than 35 C group
were largely due to the development of organ/space infections (P <
0.001), although all SSI classes were increased. Although 46.3% of
patients with an intraoperative temperature nadir less than 35 C developed SSI, only 30.5% (P < 0.001) of those whose nadir was 35 C

C 2012 Lippincott Williams & Wilkins

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Annals of Surgery r Volume 255, Number 4, April 2012

Effects of Intraoperative Hypothermia

TABLE 1. Clinical Parameters and Outcomes Compared With Respect to SSI

Patient Characteristics
Age, yrs, mean SD
BMI, kg/m2 , mean SD
Tobacco, n (%)
Injury mechanism, n (%)
Gunshot wound
Stab wound
Blunt
Injury severity score, mean SD
Penetrating abdominal trauma index, mean SD
Preoperative care, n (%)
SBP nadir < 90 mm Hg
Preincisional antibiotics
Intraoperative and postoperative care
SBP nadir <90 mm Hg, n (%)
FIO2 , mean SD
Body temperature nadir, C, mean SD
Number of measurements <35.0 C, mean SD
Peak blood glucose, units, mean SD
Red blood cell transfusion, n (%)
Injuries, n (%)
Stomach
Duodenum
Small bowel
Colon
Any enteric
Pancreas
Other solid organ
Major vascular
Other
Ostomy, n (%)
Skin closure technique, n (%)
Closed
Loosely approximated
Open
Damage control closure, n (%)
Operative time, min, mean SD
Days of postoperative antibiotics, mean SD

SSI (n = 189)

No SSI (n = 335)

30.2 11.8
28.6 6.2
76 (38.7)

31.4 12.7
26.8 5.6
127 (38.8)

0.155
0.259
0.641

142 (78.5)
27 (11.7)
19 (9.2)
18.7 13.0
17.9 11.5

193 (57.3)
83 (25.2)
58 (17.2)
13.7 10.4
11.9 9.4

<0.001

69 (40.5)
170 (89.0)

63 (18.3)
318 (95.0)

<0.001
0.046

69 (40.5)
0.62 0.19
35.0 1.1
2.7 4.8
169.6 71.9
100 (52.9)

49 (14.4)
0.57 0.15
35.4 1.0
1.1 2.8
142.2 48.8
95 (28.4)

<0.001
<0.001
0.009
<0.001
<0.001
<0.001

50 (29.5)
13 (8.0)
81 (44.2)
85 (45.4)
118 (66.3)
14 (8.6)
75 (41.7)
46 (27.0)
56 (39.9)
34 (19.6)

35 (10.2)
9 (2.5)
81 (24.9)
86 (26.9)
122 (36.7)
7 (1.9)
130 (38.0)
34 (10.0)
90 (33.5)
39 (11.4)

<0.001
0.038
<0.001
<0.001
<0.001
0.004
0.853
<0.001
0.543
0.049

40 (21.2)
43 (22.8)
47 (24.9)
57 (31.2)
383.1 197.1
9.8 17.7

46 (13.7)
96 (28.7)
178 (53.1)
13 (3.9)
280.4 160.0
3.1 3.7

0.036
0.150
<0.001
<0.001
0.003
<0.001

0.002
<0.001

Clinical characteristics were compared with respect to the presence of a surgical site infection diagnosed during
either inpatient hospitalization or outpatient follow-up.
BMI indicates body mass index, SBP, systolic blood pressure; FIO2 , fraction of inhaled oxygen; SD, standard
deviation.

or more developed site infections. In addition, the actual depth of the

temperature nadir correlated with SSI developmentthe lower the
intraoperative temperature nadir, the greater the risk of postoperative
SSI (Fig. 3).
Predictors of SSI were evaluated with single and multiple
variable logistic regression analysis (Table 2). The presence of enteric injuries independently influenced the development of SSI. After
controlling for body mass index, red blood cell transfusion, enteric
injuries, and operative duration, we determined that a single intraoperative temperature measurement less than 35 C increased the site
infection risk 221% per degree below 35 C (OR: 2.21; 95% CI: 1.24
3.92, P = 0.007). Unlike the depth of intraoperative hypothermia, the
duration of hypothermia, as assessed by the number of intraoperative
temperature measurements below 35 C, did not independently impact
the development of SSI on multivariate analysis.
Inpatient outcomes were also compared with respect to SSI
developed during their hospitalization. The development of an SSI
markedly impacted secondary inpatient outcome measures (Table 3)
including respiratory failure, renal failure, other infectious complications, antibiotic duration, and intensive care unit and hospital lengths

C 2012 Lippincott Williams & Wilkins

of stay. No difference in hospital survival was appreciated between

those who developed SSI (95.7%) and those who did not (97.8%,
P = 0.255).

DISCUSSION
The most significant finding of this analysis was that intraoperative hypothermia below 35 C had a profound impact on SSI rates
after trauma laparotomy. Just as intraoperative hypothermia is an SSI
risk factor in patients undergoing elective colorectal procedures,17
we have determined that a single intraoperative temperature measurement less than 35 C during a trauma laparotomy doubled the risk
for postoperative SSI. To our knowledge, this report is the first to
implicate intraoperative hypothermia in the development of SSI after
trauma laparotomy. Our data suggest that aggressive intraoperative
warming measures will help prevent SSI and improve outcomes after
trauma laparotomy.
Intraoperative warming has been established as an effective
method to decrease postoperative SSI after head and neck, cardiothoracic, and general surgery including clean procedures, cholecystectomy, and major, open abdominal surgery including bowel
www.annalsofsurgery.com | 791

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Annals of Surgery r Volume 255, Number 4, April 2012

Seamon et al

FIGURE 2. Patients with an intraoperative temperature nadir

less than 35 C more often developed surgical site infections
than patients with a temperature nadir of 35 C or more.

FIGURE 1. Cut-point analysis of the range of lowest intraoperative temperature established the temperature most predictive
of SSI development. Locally weighted regression was used to
determine inflection points in the intraoperative temperature
nadir to SSI development relationship based on the Pearson
residuals (A). Results of different lowest intraoperative temperature values on fit of regression model; smallest value indicates
best fit (B).
resection, colorectal surgery, and now trauma surgery.17,2935 In perhaps the most influential of these reports, Kurz et al17 prospectively
randomized 200 patients undergoing elective colorectal resection for
cancer or inflammatory bowel disease to 1 of the 2 groups: either
the hypothermic group, where intraoperative core temperatures were
allowed to decrease to 34.5 C before warming measures were instituted, or the normothermic groups in which patient core temperatures
were actively maintained near 36.5 C during the procedure. The hypothermic (34.7 C 0.6 C) patients were more likely to exhibit
postoperative peripheral vasoconstriction (78% vs 22%) and more
likely to develop postoperative SSI (19% vs 6%) than their normothermic (36.6 C 0.5 C) counterparts. As alluded to by Kurz and
others,17,3638 intraoperative hypothermia reduces peripheral circulation, increasing the susceptibility of the surgical site to infection.
The mechanisms behind hypothermia-induced increased susceptibility to SSI have been partially elucidated. In an attempt to
792 | www.annalsofsurgery.com

FIGURE 3. The predicted risk of surgical site infection correlated

with the intraoperative temperature nadir depth.
prevent further heat loss, hypothermia activates the sympathetic nervous system, leading to an increase in serum norepinephrine levels,
which in turn leads to peripheral vasoconstriction of the skin and
subcutaneous tissues.36 Vasoconstriction decreases oxygen delivery
to the surgical site, creating decreased wound oxygen tensions and
relative wound hypoxia.3638 This wound hypoxia then alters the host
immune defense system through several mechanisms. Nonspecific
immunity, which relies upon the opsonization of bacteria, phagocytosis, and oxidative killing by neutrophils, is the primary method
of defense against bacterial contamination during surgical procedures. Neutrophils, which require oxygen to synthesize oxygen free
radical species necessary in the oxidative killing of bacterial contaminants during surgical procedures, are impaired in hypothermic
patients.37 Wenisch et al37 determined that intraoperative hypothermia inhibits the production of measured oxygen free radicals. Over a
4 C range (33 C37 C), measured oxygen free radicals decreased
4-fold as intraoperative core temperatures decreased. Aside from
neutrophil mediated killing, other innate immune defense events are
impaired in patients with intraoperative hypothermia. Qadan et al38
incubated monocytes at 34 C, 37 C, and 40 C to find that monocytes
incubated at 34 C expressed less major histocompatibility class II

C 2012 Lippincott Williams & Wilkins

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Annals of Surgery r Volume 255, Number 4, April 2012

Effects of Intraoperative Hypothermia

TABLE 2. Predictors of Surgical Site Infection

Parameter

Odds Ratio (95% CI) P

Single variable logistic regression

Body mass index
1.08 (1.041.11) <0.001
Injury severity score
1.05 (1.031.07)
0.020
Penetrating abdominal trauma index
1.07 (1.051.09) <0.001
Preincisional antibiotics
0.42 (0.210.84)
0.014
Systolic blood pressure <90 mm Hg
3.12 (2.074.71) <0.001

Intraoperative temperature nadir <35 C 1.51 (1.251.82) <0.001

Number of measurements <35 C
1.13 (1.071.19) <0.001
Serum glucose
1.01 (1.011.01) <0.001
Red blood cell transfusion
1.22 (1.151.28) <0.001
Stomach injury
3.64 (2.265.88) <0.001
Small bowel injury
2.37 (1.613.51) <0.001
Colon injury
2.25 (1.533.32) <0.001
Stoma creation
1.90 (1.153.15)
0.013
Damage control
7.57 (4.9411.60) <0.001
Operative duration, min
1.04 (1.031.05) <0.001
Method of skin closure
1.42 (1.201.68) <0.001
Perioperative antibiotics, days
1.18 (1.141.23) <0.001
Multiple variable logistic regression
Body mass index
1.07 (1.031.11)
0.001
Intraoperative temperature nadir <35 C 2.21 (1.243.92)
0.007
Red blood cell transfusion
1.17 (1.101.24) <0.001
Stomach injury
3.69 (2.076.59) <0.001
Small bowel injury
1.70 (1.032.79)
0.036
Colon injury
1.89 (1.143.13)
0.013
Operative duration, min
1.002 (1.0001.003) 0.007

Predictors of surgical site infection were assessed with single and multiple
variable logistic regression.

TABLE 3. Influence of Inpatient SSI on Secondary

Outcomes
Parameter

Odds Ratio (95% CI)

11.3 (6.918.4)
4.9 (2.69.4)
9.3 (5.017.3)
6.1 (2.117.7)
7.5 (4.811.6)
9.2 (5.814.6)
4.2 (2.66.6)
20.1 (18.521.7)
10.8 (9.811.9)
13.4 (12.114.6)
23.3 (21.225.4)

<0.001
<0.001
<0.001
0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

Total parenteral nutrition

Deep venous thrombosis
Ventilator dependent respiratory failure
Acute renal failure
Pneumonia
Bacteremia
Urinary tract infection
Postoperative antibiotics, days
Ventilator days
Intensive care unit length of stay, days
Hospital length of stay, days

Single variable logistic regression determined that inpatient surgical site

infection had a marked impact on secondary clinical outcomes. Continuous variables are accompanied by regression coefficients standard errors instead of odds
ratios 95% confidence intervals.

molecules on their cell surface, had altered inflammatory cytokine

tumor necrosis factor- clearance, and increased anti-inflammatory
cytokine interleukin-10 release, suggesting a mechanistic role for
these processes during hypothermia induced SSI. Although we did
not study its pathogenic mechanisms, we studied the outcome of these
events in our trauma population and found results similar to those of
prior general surgery and colorectal surgery reportsintraoperative
hypothermia, as indicated by a single measurement of less than 35 C,
adversely affects patient outcomes by encouraging postoperative SSI.
Several of our findings merit attention. Although reported SSI
rates after trauma laparotomy have ranged from 9% to 32%,1828
our SSI rate after laparotomy was 36%. This greater SSI rate in our

C 2012 Lippincott Williams & Wilkins

study may reflect the fact that we included SSIs that developed after
hospital discharge. Our report includes not only inpatient-diagnosed
SSI, but also SSI diagnosed within 30 days of surgery, including
those diagnosed during outpatient follow-up, emergency department
visits, and hospital readmissions. In all, 14% of SSI were diagnosed
after hospital discharge, increasing our inpatient SSI rate from 31%
to an overall 36%. Other factors may also have impacted the SSI rate
reported here. To determine the effect of intraoperative hypothermia
on SSI, only patients at the greatest risk for SSI who survived 4 days or
more were included in the study analysis, whereas those who survived
less than 4 days were excluded. This likely increased our SSI rate
here because SSI is rarely diagnosed in patients who succumb within
4 days of trauma laparotomy. Finally, patients who underwent damage
control procedures requiring reopening of recent laparotomies were
included in this analysisan inclusion which likely elevated our
overall SSI rate as 31% of our patients who developed SSI underwent
temporary, damage control closures.
Although trauma surgeons obviously cannot change injury
mechanism, injury severity, injury anatomy, or presenting physiology, in this analysis, we have identified several modifiable clinical
variables that may potentially improve the outcomes of injured patients. Preincisional antibiotics were utilized in 93% of the entire
study population, but less commonly in those who developed SSI,
underscoring the importance of adhering to this SCIP guideline.912
As indicated in previous reports, blood transfusion, skin closure technique, and operative duration all impact the development of SSI.1828
Although these factors influenced the development of SSI in our analysis and highlight potential areas for performance improvement, the
presence of intraoperative hypothermia independently predicted the
development of SSI when other potential confounders were controlled
for in the multivariate logistic regression. Importantly, the effects of
hypothermia were not limited to SSI because SSI greatly impacted
secondary clinical outcome measures as well. These data suggest
that intraoperative normothermia, an SCIP guideline for colorectal
surgical procedures, should also be strictly maintained in patients
undergoing operative trauma procedures.
Interestingly, the definition of hypothermia has varied from
34 C to 36 C.3947 The association of hypothermia, classically defined by core body temperatures less than 35 C, with severe injury is
well defined in trauma literature.3947 These reports, however, focused
on the impact of hypothermia on mortality, not the development of
SSI. For these 2 reasons, we performed a cut-point analysis to define a
specific temperature value below which patients will more likely develop SSI. By analyzing the entire range of intraoperative temperature
nadir measurements, we have determined that a temperature cut-point
value less than 35 C best predicted the development of postoperative
SSIa statistically derived value identical to the classic definition
of hypothermia. Intraoperative temperature measurements below this
cut-point value were relatively common in our series. Although more
than 30% of our patients had a nadir less than 35 C, others have reported greater intraoperative hypothermia rates.4142 Gregory et al41
reported that 57% of patients became hypothermic (<36 C) during
the postinjury or intraoperative period. Bernabei et al42 analyzed the
effects of pre- and intraoperative hypothermia on operative blood
loss during trauma laparotomy and discovered that 47% of patients
in their series developed intraoperative hypothermia (<35 C). The
frequency of intraoperative hypothermia, along with its noted impact
on postoperative SSI development, suggests that aggressive intraoperative warming measures may effectively decrease SSI after trauma
laparotomy.
Although our sample size is substantial, this report represents the retrospective experience of a single center. Limitations are
inherent in the retrospective design. All clinical perioperative and
operative decisions were left to the discretion of the attending trauma
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Annals of Surgery r Volume 255, Number 4, April 2012

Seamon et al

surgeon, not a study protocol. These individual decisions included

variables such as the choice of operative procedure, the management
of perioperative antibiotics, and the diagnoses of SSI. As most exploratory trauma laparotomies were unique and were often combined
with other surgical procedures, we were unable to utilize a validated
method of SSI risk adjustment, such as that developed by the National
Nosocomial Infection Surveillance System, which relies upon operative duration norms. Despite undergoing major abdominal surgery,
outpatient follow-up was incomplete. Forty-eight percent of patients
were seen either in the outpatient clinic or emergency department
within 30 days. We recognize that our patients may have sought medical attention elsewhere at one of several nearby trauma centers. As
we rarely see trauma patients with SSI from these other centers, we
similarly believe that our patients would most likely return to our
hospital with clinical problems.
In conclusion, we have determined that intraoperative hypothermia less than 35 C adversely affects SSI rates after trauma
laparotomy. Just as intraoperative hypothermia is an SSI risk factor
in patients undergoing elective colorectal procedures, we have established that a single intraoperative measurement below the cut-point
temperature value of 35 C doubled the risk for postlaparotomy SSI
in trauma patients. Our results suggest that intraoperative normothermia, an SCIP guideline for elective colorectal surgical procedures,
should also be strictly maintained in patients undergoing operative
trauma procedures. Efforts directed toward the aggressive maintenance of intraoperative warming measures in injured patients undergoing laparotomy will likely reduce SSI rates and improve clinical
outcomes.

ACKNOWLEDGMENT
The authors thank the past and present members of the Section
of Trauma at Temple University Hospital who performed the majority of these laparotomies. Without the dedication and surgical skill
of Amy J. Goldberg, Thomas A. Santora, Abhijit S. Pathak, Kevin
M. Bradley, and Paola G. Pieri, this analysis would not have been
possible.

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