Prevention of hypothermia in newborn submitted to surgical procedures: an integrative review Translated title: Prevención de la hipotermia en recién nacido procedimientos quirúrgicos: revisión integrative Translated title: Prevenção da hipotermia em recém-nascido submetido a procedimentos cirúrgicos: revisão integrativa
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Abstract
ABSTRACT Objective: to discuss in the scientific literature the strategies used to
prevent hypothermia in newborns undergoing surgical procedures. Methods this is an
integrative literature review, with structured search in April and May 2020 in 08
databases, using the descriptors: Hypothermia; Surgical Procedures, Operative; Infant,
Newborn; Protocols. Four primary studies were selected and analyzed using three instruments
to assess the methodological quality of the Joanna Briggs Institute and content analysis.
Results: Among the strategies used, the following stand out: room temperature control;
establishment of humidification and quality of air conditioning cleanliness; use of
a heated incubator or cradle; use of thermal mattress; use of caps and blanket; heated
fluids; temperature monitoring and abdominal organ coverage. Conclusion good hypothermia
prevention strategies were identified, despite the small number of publications on
this topic; thus, it points out the need for research with strong evidence.
Translated abstract
RESUMEN Objetivo: discutir, en la literatura científica, las estrategias utilizadas
para prevenir la hipotermia en recién nacidos sometidos a procedimientos quirúrgicos.
Métodos: revisión integrativa de la literatura, con búsqueda estructurada en abril
y mayo de 2020 en 08 bases de datos, utilizando los descriptores: Hypothermia; Surgical
Procedures, Operative; Infant, Newborn; Protocols. Se seleccionaron y analizaron cuatro
estudios primarios utilizando tres instrumentos para evaluar la calidad metodológica
del Instituto Joanna Briggs y el análisis de contenido. Resultados: entre las estrategias
empleadas destacan: control de la temperatura ambiente; establecimiento de humidificación
y calidad de aire acondicionado limpio; uso de una incubadora o cuna con calefacción;
uso de colchón térmico; uso de gorros y mantas; fluidos calentados; monitoreo de temperatura;
cobertura de órganos abdominales. Conclusión: se identificaron buenas estrategias
de prevención de la hipotermia, a pesar del escaso número de publicaciones sobre este
tema; por lo tanto, señala la necesidad de realizar investigaciones con evidencia
sólida.
Translated abstract
RESUMO Objetivo: discutir, na literatura científica, as estratégias utilizadas para
prevenção de hipotermia em recém-nascido submetido a procedimentos cirúrgicos. Métodos:
revisão integrativa de literatura, com busca estruturada em abril e maio de 2020 em
08 bases de dados, utilizando os descritores: Hypothermia; Surgical Procedures, Operative;
Infant, Newborn; Protocols. Foram selecionados e analisados 04 estudos primários por
meio de três instrumentos para avaliação da qualidade metodológica da Joanna Briggs
Institute e da análise de conteúdo. Resultados: dentre as estratégias utilizadas
destaca-se: controle da temperatura ambiente; estabelecimento de umidificação e qualidade
de limpeza do ar condicionado; utilização de incubadora ou berço aquecido; uso de
colchão térmico; uso de toucas e cobertor; fluidos aquecidos; monitoramento da temperatura;
cobertura de órgãos abdominais. Conclusão: identificaram-se boas estratégias de prevenção
de hipotermia, apesar de haver um número reduzido de publicações nesta temática; dessa
forma, aponta-se a necessidade de pesquisas com evidências fortes.
Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field,1,2 and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research,3 and some health care journals are moving in this direction.4 As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in 4 leading medical journals in 1985 and 1986 and found that none met all 8 explicit scientific criteria, such as a quality assessment of included studies.5 In 1987, Sacks and colleagues6 evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in 6 domains. Reporting was generally poor; between 1 and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement.7 In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials.8 In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Terminology The terminology used to describe a systematic review and meta-analysis has evolved over time. One reason for changing the name from QUOROM to PRISMA was the desire to encompass both systematic reviews and meta-analyses. We have adopted the definitions used by the Cochrane Collaboration.9 A systematic review is a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review. Statistical methods (meta-analysis) may or may not be used to analyze and summarize the results of the included studies. Meta-analysis refers to the use of statistical techniques in a systematic review to integrate the results of included studies. Developing the PRISMA Statement A 3-day meeting was held in Ottawa, Canada, in June 2005 with 29 participants, including review authors, methodologists, clinicians, medical editors, and a consumer. The objective of the Ottawa meeting was to revise and expand the QUOROM checklist and flow diagram, as needed. The executive committee completed the following tasks, prior to the meeting: a systematic review of studies examining the quality of reporting of systematic reviews, and a comprehensive literature search to identify methodological and other articles that might inform the meeting, especially in relation to modifying checklist items. An international survey of review authors, consumers, and groups commissioning or using systematic reviews and meta-analyses was completed, including the International Network of Agencies for Health Technology Assessment (INAHTA) and the Guidelines International Network (GIN). The survey aimed to ascertain views of QUOROM, including the merits of the existing checklist items. The results of these activities were presented during the meeting and are summarized on the PRISMA Website. Only items deemed essential were retained or added to the checklist. Some additional items are nevertheless desirable, and review authors should include these, if relevant.10 For example, it is useful to indicate whether the systematic review is an update11 of a previous review, and to describe any changes in procedures from those described in the original protocol. Shortly after the meeting a draft of the PRISMA checklist was circulated to the group, including those invited to the meeting but unable to attend. A disposition file was created containing comments and revisions from each respondent, and the checklist was subsequently revised 11 times. The group approved the checklist, flow diagram, and this summary paper. Although no direct evidence was found to support retaining or adding some items, evidence from other domains was believed to be relevant. For example, Item 5 asks authors to provide registration information about the systematic review, including a registration number, if available. Although systematic review registration is not yet widely available,12,13 the participating journals of the International Committee of Medical Journal Editors (ICMJE)14 now require all clinical trials to be registered in an effort to increase transparency and accountability.15 Those aspects are also likely to benefit systematic reviewers, possibly reducing the risk of an excessive number of reviews addressing the same question16,17 and providing greater transparency when updating systematic reviews. The PRISMA Statement The PRISMA Statement consists of a 27-item checklist (Table 1; see also Text S1 for a downloadable template for researchers to re-use) and a 4-phase flow diagram (Figure 1; see also Figure S1 for a downloadable template for researchers to re-use). The aim of the PRISMA Statement is to help authors improve the reporting of systematic reviews and meta-analyses. We have focused on randomized trials, but PRISMA can also be used as a basis for reporting systematic reviews of other types of research, particularly evaluations of interventions. PRISMA may also be useful for critical appraisal of published systematic reviews. However, the PRISMA checklist is not a quality assessment instrument to gauge the quality of a systematic review. Box 1 Conceptual issues in the evolution from QUOROM to PRISMA Figure 1 Flow of information through the different phases of a systematic review Table 1 Checklist of items to include when reporting a systematic review or meta-analysis From QUOROM to PRISMA The new PRISMA checklist differs in several respects from the QUOROM checklist, and the substantive specific changes are highlighted in Table 2. Generally, the PRISMA checklist “decouples” several items present in the QUOROM checklist and, where applicable, several checklist items are linked to improve consistency across the systematic review report. Table 2 Substantive specific changes between the QUOROM checklist and the PRISMA checklist (a tick indicates the presence of the topic in QUOROM or PRISMA) The flow diagram has also been modified. Before including studies and providing reasons for excluding others, the review team must first search the literature. This search results in records. Once these records have been screened and eligibility criteria applied, a smaller number of articles will remain. The number of included articles might be smaller (or larger) than the number of studies, because articles may report on multiple studies and results from a particular study may be published in several articles. To capture this information, the PRISMA flow diagram now requests information on these phases of the review process. Endorsement The PRISMA Statement should replace the QUOROM Statement for those journals that have endorsed QUOROM. We hope that other journals will support PRISMA; they can do so by registering on the PRISMA Website. To underscore to authors, and others, the importance of transparent reporting of systematic reviews, we encourage supporting journals to reference the PRISMA Statement and include the PRISMA web address in their Instructions to Authors. We also invite editorial organizations to consider endorsing PRISMA and encourage authors to adhere to its principles. The PRISMA Explanation and Elaboration Paper In addition to the PRISMA Statement, a supporting Explanation and Elaboration document has been produced18 following the style used for other reporting guidelines.19-21 The process of completing this document included developing a large database of exemplars to highlight how best to report each checklist item, and identifying a comprehensive evidence base to support the inclusion of each checklist item. The Explanation and Elaboration document was completed after several face-to-face meetings and numerous iterations among several meeting participants, after which it was shared with the whole group for additional revisions and final approval. Finally, the group formed a dissemination subcommittee to help disseminate and implement PRISMA. Discussion The quality of reporting of systematic reviews is still not optimal.22-27 In a recent review of 300 systematic reviews, few authors reported assessing possible publication bias,22 even though there is overwhelming evidence both for its existence28 and its impact on the results of systematic reviews.29 Even when the possibility of publication bias is assessed, there is no guarantee that systematic reviewers have assessed or interpreted it appropriately.30 Although the absence of reporting such an assessment does not necessarily indicate that it was not done, reporting an assessment of possible publication bias is likely to be a marker of the thoroughness of the conduct of the systematic review. Several approaches have been developed to conduct systematic reviews on a broader array of questions. For example, systematic reviews are now conducted to investigate cost-effectiveness,31 diagnostic32 or prognostic questions,33 genetic associations,34 and policy-making.35 The general concepts and topics covered by PRISMA are all relevant to any systematic review, not just those whose objective is to summarize the benefits and harms of a health care intervention. However, some modifications of the checklist items or flow diagram will be necessary in particular circumstances. For example, assessing the risk of bias is a key concept, but the items used to assess this in a diagnostic review are likely to focus on issues such as the spectrum of patients and the verification of disease status, which differ from reviews of interventions. The flow diagram will also need adjustments when reporting individual patient data meta-analysis.36 We have developed an explanatory document18 to increase the usefulness of PRISMA. For each checklist item, this document contains an example of good reporting, a rationale for its inclusion, and supporting evidence, including references, whenever possible. We believe this document will also serve as a useful resource for those teaching systematic review methodology. We encourage journals to include reference to the explanatory document in their Instructions to Authors. Like any evidence-based endeavour, PRISMA is a living document. To this end we invite readers to comment on the revised version, particularly the new checklist and flow diagram, through the PRISMA website. We will use such information to inform PRISMA's continued development. Note: To encourage dissemination of the PRISMA Statement, this article is freely accessible on the Open Medicine website and the PLoS Medicine website and is also published in the Annals of Internal Medicine, BMJ, and Journal of Clinical Epidemiology. The authors jointly hold the copyright of this article. For details on further use, see the PRISMA website. The PRISMA Explanation and Elaboration Paper is available at the PLoS Medicine website. Supporting Information Figure S1 Flow of information through the different phases of a systematic review (downloadable template document for researchers to re-use) Text S1 Checklist of items to include when reporting a systematic review or meta-analysis (downloadable template document for researchers to re-use)
The aim of this paper is to distinguish the integrative review method from other review methods and to propose methodological strategies specific to the integrative review method to enhance the rigour of the process. Recent evidence-based practice initiatives have increased the need for and the production of all types of reviews of the literature (integrative reviews, systematic reviews, meta-analyses, and qualitative reviews). The integrative review method is the only approach that allows for the combination of diverse methodologies (for example, experimental and non-experimental research), and has the potential to play a greater role in evidence-based practice for nursing. With respect to the integrative review method, strategies to enhance data collection and extraction have been developed; however, methods of analysis, synthesis, and conclusion drawing remain poorly formulated. A modified framework for research reviews is presented to address issues specific to the integrative review method. Issues related to specifying the review purpose, searching the literature, evaluating data from primary sources, analysing data, and presenting the results are discussed. Data analysis methods of qualitative research are proposed as strategies that enhance the rigour of combining diverse methodologies as well as empirical and theoretical sources in an integrative review. An updated integrative review method has the potential to allow for diverse primary research methods to become a greater part of evidence-based practice initiatives.
Core body temperature is normally tightly regulated to within a few tenths of a degree. The major thermoregulatory defences in humans are sweating, arteriovenous shunt vasoconstriction, and shivering. The core temperature triggering each response defines its activation threshold. General anaesthetics greatly impair thermoregulation, synchronously reducing the thresholds for vasoconstriction and shivering. Neuraxial anaesthesia also impairs central thermoregulatory control, and prevents vasoconstriction and shivering in blocked areas. Consequently, unwarmed anaesthetised patients become hypothermic, typically by 1-2°C. Hypothermia results initially from an internal redistribution of body heat from the core to the periphery, followed by heat loss exceeding metabolic heat production. Complications of perioperative hypothermia include coagulopathy and increased transfusion requirement, surgical site infection, delayed drug metabolism, prolonged recovery, shivering, and thermal discomfort. Body temperature can be reliably measured in the oesophagus, nasopharynx, mouth, and bladder. The standard-of-care is to monitor core temperature and to maintain normothermia during general and neuraxial anaesthesia.
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