From Hypothermia Prevention to Hyperthermia Crisis: Iatrogenic Temperature Disturbance in Paediatric Anaesthesia

Abstract

Background: Maintenance of normothermia is a cornerstone of perioperative care in children, and active warming methods are routinely employed to prevent hypothermia. However, inadvertent hyperthermia can occur and may lead to serious complications.

Case Presentation: We report the case of a 10-month-old infant (8 kg, ASA I) scheduled for cleft palate repair. Anaesthesia was induced with sevoflurane, fentanyl, and atracurium, and maintained with sevoflurane in oxygen/nitrous oxide. Intraoperatively, active warming with a forced-air device was employed. After two hours, the child developed progressive tachycardia (HR 160–200/min) with warm peripheries. Rectal temperature measured 40 °C. Shortly thereafter, ventricular tachycardia was noted. Sevoflurane was discontinued, active cooling was initiated, and intravenous lignocaine, calcium gluconate, and furosemide were administered. The arrhythmia reverted to sinus rhythm, and temperature normalized with supportive measures. The child was extubated uneventfully and had a smooth postoperative recovery.

Conclusion: This case highlights the potential hazards of perioperative warming devices in infants, where high surface-area-to-weight ratio predisposes to rapid heat gain. Routine temperature monitoring is essential in paediatric surgeries, even for procedures of short expected duration, to detect and prevent iatrogenic hyperthermia.