围术期体温管理：生理、监测与临床实践综述

Perioperative Temperature Management: A Review of Physiology, Monitoring, and Clinical Practice

摘要: 背景：非计划性围术期低体温(IPH)定义为围术期核心体温低于36℃，是麻醉实践中最常见的体温异常，发生率高达50%~90%。Meta分析显示，IPH可使手术部位感染(SSI)风险增加约60% (OR = 1.60, 95% CI: 1.14~2.23)，当核心体温 ≤ 35℃时SSI风险进一步升高至2.12倍(OR = 2.12, 95% CI: 1.42~3.16)；同时IPH与术中出血量增加(MD = 131.90 mL, 95% CI: 117.42~146.38 mL)、寒战发生率升高(风险差RD = 0.32)、凝血功能障碍、药物代谢延缓及住院时间延长密切相关。尽管体温监测与保温技术已有进展，但临床实践中监测不充分、保温策略执行不规范仍导致IPH高发。目的：系统综述围术期体温调节的生理学基础、体温监测技术、主动保温策略的循证依据，以及老年人、儿童、创伤等特殊人群的个体化管理方案，为临床提供基于循证医学的体温管理指导。主要内容：1) 生理学基础：全身麻醉使体温调定点下移0.2℃~0.5℃，寒战阈值降低2℃~3℃，麻醉诱导后30~60分钟内核心体温因热量再分布急剧下降1℃~1.5℃；2) 监测技术：核心温度监测(肺动脉、食管、膀胱、鼻咽)为金标准，零热通量技术与食管温度偏差 < 0.3℃，无线可穿戴传感器与食管温度平均差值仅0.05℃；3) 主动保温：充气式加温可将IPH发生率从50%~70%降至10%~20%，预保温联合术中加温可使低体温风险降低约80% (OR = 0.20)，每输注1 L室温液体可使核心体温下降约0.25℃；4) 特殊人群：老年人IPH发生率70%~90%，儿童80%~90%，创伤患者60%~80%，均需个体化强化保温策略。核心结论：围术期体温管理应构建“监测–评估–干预–再评估”的闭环管理模式：以核心温度连续监测为起点，动态评估患者热平衡状态，及时启动多模式主动保温干预，并通过再监测验证干预效果、动态调整方案，方能有效降低IPH及其相关并发症，改善患者预后。

Abstract: Background: Inadvertent perioperative hypothermia (IPH), defined as a core body temperature below 36˚C during the perioperative period, is the most common thermal abnormality in anesthesia practice, with an incidence of 50%~90%. Meta-analyses indicate that IPH increases the risk of surgical site infection (SSI) by approximately 60% (OR = 1.60, 95% CI: 1.14~2.23), and when core temperature drops to ≤35˚C, the SSI risk further rises to 2.12-fold (OR = 2.12, 95% CI: 1.42~3.16). IPH is also associated with increased intraoperative blood loss (MD = 131.90 mL, 95% CI: 117.42~146.38 mL), elevated shivering incidence (risk difference RD = 0.32), coagulopathy, delayed drug metabolism, and prolonged hospital stay. Despite advances in temperature monitoring and warming techniques, inadequate monitoring and non-standard implementation of warming strategies continue to drive the high incidence of IPH. Objective: To systematically review the physiological basis of perioperative thermoregulation, temperature monitoring techniques, evidence-based active warming strategies, and individualized management for special populations including the elderly, children, and trauma patients, so as to provide evidence-based guidance for clinical perioperative temperature management. Main Contents: 1) Physiological basis: general anesthesia lowers the hypothalamic set point by 0.2˚C~0.5˚C and the shivering threshold by 2˚C~3˚C; core temperature drops sharply by 1˚C~1.5˚C within 30~60 minutes after induction due to heat redistribution. 2) Monitoring techniques: core temperature monitoring (pulmonary artery, esophageal, bladder, nasopharyngeal) remains the gold standard; zero-heat-flux technology shows a bias < 0.3˚C versus esophageal temperature, and wireless wearable sensors have a mean difference of only 0.05˚C. 3) Active warming: forced-air warming reduces IPH incidence from 50%~70% to 10%~20%; prewarming combined with intraoperative warming reduces hypothermia risk by approximately 80% (OR = 0.20); each liter of room-temperature fluid infused lowers core temperature by about 0.25˚C. 4) Special populations: IPH incidence reaches 70%~90% in the elderly, 80%~90% in children, and 60%~80% in trauma patients, all requiring individualized intensive warming strategies. Core Conclusions: Perioperative temperature management should establish a closed-loop “monitoring-assessment-intervention-reassessment” model: starting with continuous core temperature monitoring, dynamically evaluating the patient’s thermal balance, promptly initiating multimodal active warming interventions, and verifying efficacy through reassessment to dynamically adjust the plan—this is the key to effectively reducing IPH and its related complications and improving patient outcomes.