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Another use for the forced air warmer

Calgary, Alberta

To the Editor:

A 14-yr-old, developmentally delayed girl presented for emergency debulking of a cerebral tumour. As a result of hemorrhage into the tumour she had become comatose and had been placed on mechanical ventilation. Vital signs revealed a heart rate of 140•min^-1, blood pressure of 125/80 mmHg and a nasopharyngeal temperature of 39°C. The peripheries were noted to be cool, despite the patient’s febrile condition, with delayed capillary refill, but a satisfactory oxygen saturation of 98% was obtained by pulse oximetry. Anesthesia and surgery proceeded uneventfully until two hours into the case, when the pulse oximeter waveform became smaller and the value for oxygen saturation began to fall. Manual ventilation with 100% did not improve the displayed oxygen saturation. Hemodynamic status and end-tidal CO₂ remained unchanged. The surgeon felt that air embolus was very unlikely at that time in the procedure. The extremities were again noted to be poorly perfused and the recorded oxygen saturation was found to be equally low (approximately 60%) or unrecordable in both hands and feet. An arterial blood gas revealed a PO₂ of 492 mmHg, suggesting that the problem was with poor peripheral perfusion, not hypoxemia. Volume loading failed to improve the peripheral perfusion and the waveform and value remained unreliable for 30 min. An attempt was then made to improve peripheral perfusion by the local use of a forced air warmer to a foot. Within five minutes, a satisfactory waveform was re-established and oxygen saturations of 100% were obtained. The waveform and values remained satisfactory for the rest of the case. This event demonstrated that a forced air warmer can improve peripheral perfusion to an extremity and improve the reliability of a poorly functioning pulse oximeter. Two caveats exist. Firstly, the reason for poor perfusion should also be sought and treated (e.g., hypovolemia, sepsis). Secondly, great care must be taken to avoid thermal injury by appropriate diffusion of air flow and regular inspection of the limb.

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