- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03581721
Prevention of Maternal Hypothermia After Scheduled Caesarean Section Using Active Intravenous Warming (CESAR-RESOL2)
Prevention of Maternal Hypothermia After Scheduled Caesarean Section Using Active IV Fluid Warming: a Randomized Controlled Trial
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Hypothermia is a well-known complication of general and neuraxial anaesthesia. After a caesarean section under spinal anaesthesia, 30 to 40% of the mothers have a core temperature <36°C. Perioperative hypothermia induces maternal thermal discomfort and shivering, but also increases the amount of blood loss and the risks of postoperative wound infections and cardiac complications. In addition, maternal hypothermia may also have an impact on neonatal outcomes. Prevention of maternal hypothermia in women scheduled for caesarean delivery is consequently necessary, and is an important part of enhanced recovery after surgery. Active warming is efficient in preventing postoperative hypothermia. Forced-air warming is the most commonly used modality of active warming. However forced-air warming should be applied for at least 60 minutes to be efficient. As surgical duration for a caesarean is lower than one hour, this technic does not appear really appropriate in this context. In addition, upper body forced-air warming is uncomfortable for women and can interfere with bonding. Consequently forced-air warming is not generally used during caesarean delivery. Warmed IV fluid is another option to prevent perioperative hypothermia, but with contrasting results, depending mainly on the device and on the amount of perioperative fluids infusion. Co-loading IV fluid is recommended to prevent maternal hypotension induced by spinal anaesthesia in the context of caesarean delivery. Small released fluid warmings routinely used in scheduled surgery, are able to warm IV fluid administered with high flows, such as in co-loading IV fluid. But the efficiency of these devices to prevent maternal hypothermia has never been explored in the context of caesarean section under spinal anaesthesia with co-loading.
The investigators hypothesized that warmed IV fluid administered in co-loading with enFlow® or Fluido®Compact decreases the incidence of postoperative maternal hypothermia after caesarean section under spinal anaesthesia.
The investigators will perform a double blinded randomized controlled trial comparing active IV warming with enFlow® or Fluido®Compact versus placebo.
Indeed at the beginning of the study, the performance of the enFlow device were tested. But in February 2019, a study published in Anaesthesia showed that uncoated aluminium plates in fluid warming systems, such as those used in the enFlow system, yielded potentially harmful concentrations of aluminium when using balanced electrolyte solutions (ref Perl Anaesthesia 2019). Consequently this device was quarantined unless there are no alternative fluid warmers available Of note no adverse event has been reported associated with the use of enFlow® device. Consequently, we choose to continue our study with the Fluido®Compact, which is a very similar small fluid warmer but with coated aluminium plate.
After obtaining written informed consent from the patients, 70 pregnant women ASA status 1 or 2 and scheduled for caesarean delivery will be enrolled and randomized into two groups: active IV fluid warming vs no active warming. Written informed consent will be obtained before randomisation using an Internet based randomisation system. Participants will be randomized just after their arrival in the operative room. The clinicians in charge of the patients, the researcher and the woman will be blinded. In the operative room, a venous cannula will be inserted into the forearm, and an infusion of Ringer's lactate solution fluids will be initiated. An enFlow® or Fluido®Compact device will be placed on the IV for all the patients, but turned on only in the group active warming. The device will be hidden in all the patients. Every patient will have a spinal anaesthesia in sitting position with hyperbaric bupivacaine 10mg, sufentanil 3µg and morphine 100µg. An IV co loading with Ringer-Lactate 1000 ml will be started at the beginning of the spinal administration. All the women will be monitored using heart rate, continuous SpO2, non-invasive arterial blood pressure every 1-minute until the baby is born, and then every 5 minutes. Maternal arterial hypotension will be corrected with ephedrine or phenylephrine as appropriate. All the women will receive carbetocin 100µg just after baby extraction. While in the operative room, all the data will be collected on a standardized data collection sheet. In case of maternal temperature <35°C during surgery, an active warming blanket will be used. The enFlow® or Fluido®Compact device will be taken off at the end of the surgery just before leaving the operative room.
In addition, postoperative data will be collected during the admission to the post-anaesthesia care unit (PACU). In case of maternal temperature <36°C in the PACU, a warming blanket will be used.
The sample size calculation revealed that 62 participants were required to ensure that a 30% decrease in the incidence of postoperative maternal hypothermia will be detected (power = 0.9 ; α= 0,05). The investigators decided to enroll 70 women because of the risks of secondary exclusions and of lost of follow up.
Study Type
Enrollment (Anticipated)
Phase
- Not Applicable
Contacts and Locations
Study Locations
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Paris, France, 75014
- Cochin Hospital, Port-Royal Maternity
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
Pregnant women
- without any major co-morbidity (ASA status 1 or 2),
- with normal singleton pregnancy,
- who will deliver by scheduled caesarean section under spinal anesthesia at gestational age ≥ 37 weeks of amenorrhea,
- Aged ≥ 18 years
- with health insurance
Exclusion Criteria:
- Patient refusal to participate in the study
- Maternal temperature ≥38.0 ° C or <36.0 ° C at the time of randomization,
- Spinal anaesthesia refused or contraindicated,
- unplanned caesarean section
- caesarean delivery scheduled since less than 48 hours
- caesarean section performed under epidural or general anesthesia
- participation of the mother in another interventional research or intervention, or during the exclusion period following a previous search
- unability to give written consent
- body mass index> 40kg / m2
- gravidic hypertensive disease
- uncontrolled diabetes
- cardiovascular disease under treatment
- coagulation disorder
Study Plan
How is the study designed?
Design Details
- Primary Purpose: PREVENTION
- Allocation: RANDOMIZED
- Interventional Model: PARALLEL
- Masking: QUADRUPLE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
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NO_INTERVENTION: The control group
Control group according to usual practices: no active warming (no fluid warming).
The fluid warmer device will be set up but not activated.
The control group will receive IV fluid coload at room temperature through the fluid warmer set to "off".
The device is hidden
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EXPERIMENTAL: The warming group
"IV fluid warming with the enFlow® or Fluido®Compact IV fluid warmer" : Women will receive IV fluid coload warmed to 40°C through the enFlow® or Fluido®Compact device.
The box will be also hidden.
The fluid warmer will be turned off at the end of surgery, just before transfer to the PACU.
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The fluid warmer will be set up by an external co-investigator in every patient included in the study.
It will be turned on in patients belonging to the "warming" group, and turned off in the control group
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Incidence of Maternal postoperative hypothermia
Time Frame: until Hour 12
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Obtained by placing a skin sensor on the right temporal region and measured using the 3M™ SpotOn™ Monitoring System on arrival at the PACU Hypothermia is defined as a Temperature <36°C
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until Hour 12
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Maternal Shivering
Time Frame: Until Hour 12
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Measured on a 4 points scale (0 = no chills, 1 = intermittent, low intensity, 2 = moderate, 3 = continuous) Just before the spinal anesthesia and every 10 minutes in the operative room
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Until Hour 12
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Maternal shivering
Time Frame: Until Hour 12
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Score of 4 points (0 = no chills, 1 = intermittent, low intensity, 2 = moderate, 3 = continuous and intense) On arrival at SSPI, one hour and 2 hours after, and just before leaving the PACU
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Until Hour 12
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Maternal Thermal discomfort
Time Frame: until Hour 12
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Visual analogic scale between 0 and 100 (0: absence of thermal discomfort, 100: extreme thermal discomfort) Just before the spinal anesthesia and every 10 min during the surgery
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until Hour 12
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Maternal Thermal discomfort
Time Frame: Until Hour 12
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Numerical scale between 0 and 100 (0: absence of thermal discomfort, 100: extreme thermal discomfort) On arrival at SSP, one hour and 2 hours after, and just before leaving the PACU
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Until Hour 12
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Need of active maternal warming
Time Frame: Until Hour 12
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use of a air forced warming blanked, peroperatively and Until H2 after surgery
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Until Hour 12
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Neonatal core hypothermia
Time Frame: Within 30th minutes of life
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Measure of Temperature °C with cutaneous thermometer
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Within 30th minutes of life
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Apgar score
Time Frame: minute 1 after birth
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Clinically evaluated
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minute 1 after birth
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Apgar score
Time Frame: minute 5 after birth
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Clinically evaluated
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minute 5 after birth
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Apgar score
Time Frame: minute 10 after birth
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Clinically evaluated :assessment of the newborn infant well-being
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minute 10 after birth
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Arterial umbilical pH measurement (physiological parameter)
Time Frame: Within 30th minutes of life
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Blood test
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Within 30th minutes of life
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Arterial umbilical base deficit measurement
Time Frame: Within 30th minutes of life
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Blood test
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Within 30th minutes of life
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Variation in perioperative hemoglobinemia
Time Frame: Within 24hours before cesarean and one day after surgery
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Blood test
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Within 24hours before cesarean and one day after surgery
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Hemoglobin concentration
Time Frame: one day after surgery
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blood test
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one day after surgery
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Postpartum anemia
Time Frame: One day after surgery
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Maternal hemoglobin concentration
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One day after surgery
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Maternal postoperative recovery
Time Frame: between day 3 and day 5 after surgery
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6-minute walk test (6 MWT)
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between day 3 and day 5 after surgery
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Estimation of Quality of life
Time Frame: at the time of the postoperative appointment, around 40 days after surgery
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The WHOQOL-BREF instrument comprises 26 items, which measure the following broad domains: physical health, psychological health, social relationships, and environment.
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at the time of the postoperative appointment, around 40 days after surgery
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Collaborators and Investigators
Investigators
- Principal Investigator: Marie Pierre Bonnet, MD, PhD, Assistance Publique - Hôpitaux de Paris
- Principal Investigator: Pascal Alfonsi, Saint Joseph Hospital, Paris
Publications and helpful links
General Publications
- Cobb B, Cho Y, Hilton G, Ting V, Carvalho B. Active Warming Utilizing Combined IV Fluid and Forced-Air Warming Decreases Hypothermia and Improves Maternal Comfort During Cesarean Delivery: A Randomized Control Trial. Anesth Analg. 2016 May;122(5):1490-7. doi: 10.1213/ANE.0000000000001181.
- Horn EP, Bein B, Steinfath M, Ramaker K, Buchloh B, Hocker J. The incidence and prevention of hypothermia in newborn bonding after cesarean delivery: a randomized controlled trial. Anesth Analg. 2014 May;118(5):997-1002. doi: 10.1213/ANE.0000000000000160.
- Sessler DI. Complications and treatment of mild hypothermia. Anesthesiology. 2001 Aug;95(2):531-43. doi: 10.1097/00000542-200108000-00040. No abstract available.
- Sultan P, Habib AS, Cho Y, Carvalho B. The Effect of patient warming during Caesarean delivery on maternal and neonatal outcomes: a meta-analysis. Br J Anaesth. 2015 Oct;115(4):500-10. doi: 10.1093/bja/aev325.
- Yokoyama K, Suzuki M, Shimada Y, Matsushima T, Bito H, Sakamoto A. Effect of administration of pre-warmed intravenous fluids on the frequency of hypothermia following spinal anesthesia for Cesarean delivery. J Clin Anesth. 2009 Jun;21(4):242-8. doi: 10.1016/j.jclinane.2008.12.010. Epub 2009 Jun 6.
- Perlman J, Kjaer K. Neonatal and Maternal Temperature Regulation During and After Delivery. Anesth Analg. 2016 Jul;123(1):168-72. doi: 10.1213/ANE.0000000000001256.
- Butwick AJ, Lipman SS, Carvalho B. Intraoperative forced air-warming during cesarean delivery under spinal anesthesia does not prevent maternal hypothermia. Anesth Analg. 2007 Nov;105(5):1413-9, table of contents. doi: 10.1213/01.ane.0000286167.96410.27.
Study record dates
Study Major Dates
Study Start (ACTUAL)
Primary Completion (ACTUAL)
Study Completion (ANTICIPATED)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (ACTUAL)
Study Record Updates
Last Update Posted (ACTUAL)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- K170402J
- 2017-A03139-4 (REGISTRY: ANSM)
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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