Comparison of rectal and axillary temperatures in dogs and cats

Joana B. Goic Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104.

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Erica L. Reineke Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104.

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Kenneth J. Drobatz Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104.

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Abstract

Objective—To compare rectal versus axillary temperatures in dogs and cats.

Design—Prospective observational study.

Animals—94 dogs and 31 cats.

Procedures—Paired axillary and rectal temperatures were measured in random order with a standardized method. Animal signalment, initial complaint, blood pressure, blood lactate concentration, and variables associated with vascular perfusion and coat were evaluated for associations with axillary and rectal temperatures.

Results—Axillary temperature was positively correlated with rectal temperature (ρ = 0.75 in both species). Median axillary temperature (38.4°C [101.1°F] in dogs, and 38.4°C [101.2°F] in cats) was significantly different from median rectal temperature in dogs (38.9°C [102.0°F]) but not in cats (38.6°C [101.5°F]). Median rectal-axillary gradient (difference) was 0.4°C (0.7°F; range, −1.3° to 2.3°C [−2.4° to 4.1°F]) in dogs and 0.17°C (0.3°F; range −1.1° to 1.6°C [−1.9° to 3°F]) in cats. Sensitivity and specificity for detection of hyperthermia with axillary temperature were 57% and 100%, respectively, in dogs and 33% and 100%, respectively, in cats; sensitivity and specificity for detection of hypothermia were 86% and 87%, respectively, in dogs and 80% and 96%, respectively, in cats. Body weight (ρ = 0.514) and body condition score (ρ = 0.431) were correlated with rectal-axillary gradient in cats.

Conclusions and Clinical Relevance—Although axillary and rectal temperatures were correlated in dogs and cats, a large gradient was present between rectal temperature and axillary temperature, suggesting that axillary temperature should not be used as a substitute for rectal temperature.

Abstract

Objective—To compare rectal versus axillary temperatures in dogs and cats.

Design—Prospective observational study.

Animals—94 dogs and 31 cats.

Procedures—Paired axillary and rectal temperatures were measured in random order with a standardized method. Animal signalment, initial complaint, blood pressure, blood lactate concentration, and variables associated with vascular perfusion and coat were evaluated for associations with axillary and rectal temperatures.

Results—Axillary temperature was positively correlated with rectal temperature (ρ = 0.75 in both species). Median axillary temperature (38.4°C [101.1°F] in dogs, and 38.4°C [101.2°F] in cats) was significantly different from median rectal temperature in dogs (38.9°C [102.0°F]) but not in cats (38.6°C [101.5°F]). Median rectal-axillary gradient (difference) was 0.4°C (0.7°F; range, −1.3° to 2.3°C [−2.4° to 4.1°F]) in dogs and 0.17°C (0.3°F; range −1.1° to 1.6°C [−1.9° to 3°F]) in cats. Sensitivity and specificity for detection of hyperthermia with axillary temperature were 57% and 100%, respectively, in dogs and 33% and 100%, respectively, in cats; sensitivity and specificity for detection of hypothermia were 86% and 87%, respectively, in dogs and 80% and 96%, respectively, in cats. Body weight (ρ = 0.514) and body condition score (ρ = 0.431) were correlated with rectal-axillary gradient in cats.

Conclusions and Clinical Relevance—Although axillary and rectal temperatures were correlated in dogs and cats, a large gradient was present between rectal temperature and axillary temperature, suggesting that axillary temperature should not be used as a substitute for rectal temperature.

Accurate assessment of body temperature is an important aspect of the physical examination in veterinary patients. Rectal temperature is the standard measurement used to assess body temperature in animals, but the use of axillary temperature has been described1,2 and is often used as a substitute. This is true especially when measurement of rectal temperature is complicated by animal temperament or rectal lesions or when frequent temperature monitoring is required. Although multiple studies3–25 evaluating axillary temperature in human populations have been conducted, only 1 study2 has critically evaluated axillary temperature in dogs, and to the author's knowledge, axillary temperature has not been evaluated in cats.

A large number of human studies have compared axillary temperature with internal body temperature. Although some data are conflicting, most studies have detected a wide variation between axillary and rectal temperatures in adults as well as in pediatric and neonatal populations.4,5,7–12,22,24 Sensitivity of axillary temperature for detecting fever ranges from 25% to 87.5%,8,11–13 with increased sensitivity in neonatal populations.11,17,19,21 Patient age,7,11,12 body condition,16 time of day,4 axilla of measurement,23 and presence of hemiplegia18 affect the reliability of axillary temperature, whereas IV fluid infusion,3 environmental temperature,9,12 and amount of clothing worn9 do not. Weight, body condition, breed, and coat length are associated with differences between axillary and rectal temperature in dogs.2 In humans, the gradient between core temperature and the temperature of the great toe correlates with the severity of circulatory disease,26,27 and increasing temperature of the toe in response to treatment is associated with an improved prognosis.26

Although measurement of axillary temperature is convenient and may reduce patient stress, compared with measurement of rectal temperature, it is important to establish the accuracy of axillary temperature measurements in dogs and cats before use in clinical practice. Inaccurate body temperature measurements can lead to inappropriate diagnostic and treatment decisions that may affect overall patient care. Therefore, the purpose of the study reported here was to compare axillary with rectal temperature in dogs and cats and evaluate multiple clinical variables to identify factors that may alter the accuracy of axillary temperature measurements. The hypothesis was that, as in humans, axillary temperature would not be strongly correlated with rectal temperature.

Materials and Methods

All dogs and cats evaluated at the Matthew J. Ryan Veterinary Hospital of the University of Pennsylvania between November 2011 and June 2012 were considered for inclusion in the study. Animals were included on the basis of availability of the investigators and staff to perform the measurements required. Animals were excluded if it was deemed unsafe to obtain temperature measurements, either because of animal temperament or clinical condition. Animals with axillary or rectal lesions were also excluded as well as those with paresis or paralysis localized to the axilla of measurement, those with suspected aortic thromboembolism, and those receiving heat support.

Temperature measurements—Sequential single axillary temperature and rectal temperature readings were obtained with the same thermometera; a coin flip was used to randomize the order of collection. Data were collected by the staff, students, or clinicians involved in the care of an individual animal. As adopted from human methods of axillary temperature measurements, the thermometer was placed midway between the most cranial and caudal aspects of the axilla, against the thorax, and as dorsal as possible9 until the thermometer beeped, indicating a valid temperature reading. For rectal temperature readings, the tip of the thermometer was completely inserted into the rectum, and the thermometer was gently pushed against the rectal mucosa to avoid intrafecal measurements until the thermometer beeped. A thin plastic sleeve was placed over the thermometer for rectal temperature readings. The time interval between measurements was recorded. For the purposes of analysis, hyperthermia was defined as rectal temperature ≥ 39.4°C (103°F) and hypothermia was defined as rectal temperature < 37.8°C (100°F).28

To determine whether certain factors affected the accuracy of the axillary temperature measurements, physical examination findings were recorded and included signalment, body weight, BCS, mucous membrane color, capillary refill time, pulse quality, mentation, heart rate, coat length, coat density, length of hair in the axilla, lesions in the axilla or rectum, and whether diarrhea was present in the history (large or small intestine). If the tests had been requested by the primary clinician on the basis of the animal's clinical condition, results of blood pressure and blood lactate concentration determinations were recorded. Any clinical suspicion of shock was recorded as well as the presence of hyperdynamic physical examination findings (ie, bounding pulses, red mucous membranes, or capillary refill time < 1 second). This protocol was approved by the Institutional Animal Care and Use Committee at the University of Pennsylvania.

Statistical analysis—To evaluate whether axillary temperature was consistently different from rectal temperature, an RAG was calculated for each animal by subtracting the axillary temperature from the rectal temperature. On the basis of prior veterinary studies2,28 comparing methods of temperature measurement, a difference in these 2 temperatures > 0.5°C (0.9°F) was considered clinically important.

Continuous variables (rectal temperature, axillary temperature, RAG, and body weight) were assessed for normality by use of the Shapiro-Wilk test and were not normally distributed, or the sample size was too small to consider the data to be normally distributed; therefore, median (range) values were used to describe the data for these variables. The Wilcoxon signed rank test was used for comparison of median temperatures. Spearman rank correlation analysis was used to assess the associations between rectal and axillary temperatures, RAG and BCS, and RAG and body weight. Bland-Altman analysis was used to assess the agreement between rectal and axillary temperatures. Ninety-five percent CIs for sensitivity and specificity of axillary temperature in detecting abnormal rectal temperature were calculated with the exact method. A value of P < 0.05 was considered significant for all analyses. A statistical software programb was used for the statistical analyses.

Results

Canine data—Ninety-four dogs were included in the study (42 females and 52 males; 32 breeds) and had a median age of 5 years (range, 6 weeks to 17 years) and a median weight of 17.1 kg (37.6 lb; range, 1.15 to 55.5 kg [2.5 to 122.1 lb]). Ninety-four paired temperature measurements were performed on these dogs; each paired measurement was obtained within 5 minutes, with 85% of measurements taken within 0 to 2 minutes and 15% within > 2 to 5 minutes.

Axillary and rectal temperatures were positively correlated (ρ = 0.75; P < 0.001; Figure 1), although the median axillary temperature (38.4°C [101.1°F]; range, 36° to 40.6°C [96.8° to 105.1°F]) was significantly (P < 0.001) different from the median rectal temperature (38.9°C [102.0°F]; range, 36° to 40.8°C [96.8° to 105.5°F]). Additionally, a clinically important amount of variation was found in the limits of agreement (−0.61° to 1.5°C [−1.10° to 2.7°F]) determined by Bland-Altman analysis (Figure 2).

Figure 1—
Figure 1—

Scatterplots of paired rectal and axillary temperatures in 94 dogs (A) and 31 cats (B).

Citation: Journal of the American Veterinary Medical Association 244, 10; 10.2460/javma.244.10.1170

Figure 2—
Figure 2—

Bland-Altman plots of the agreement between paired rectal and axillary temperatures in 94 dogs (A) and 31 cats (B).

Citation: Journal of the American Veterinary Medical Association 244, 10; 10.2460/javma.244.10.1170

The median RAG was 0.4°C (0.7°F; range, −1.3° to 2.3°C [−2.4° to 4.1°F]). Sixty-four percent (60/94) of dogs had an RAG ≤ 0.5°C. Eighty-percent (75/94) of dogs had a positive RAG (rectal temperature greater than axillary temperature), 6% (6/94) of dogs had equal temperatures, and 14% (13/94) had a negative RAG (rectal temperature less than axillary temperature).

Twenty-one (22.3%) dogs were hyperthermic (rectal temperature ≥ 39.4°C), 7 (7.4%) dogs were hypothermic (rectal temperature < 37.8°C), and 66 (70.2%) dogs were normothermic on the basis of rectal temperature. In the hyperthermic population, median RAG was 0.5°C (range, −0.3° to 2.0°C [−0.5° to 3.6°F]). Sensitivity for detection of hyperthermia with axillary temperature was 57% (95% CI, 34% to 78%), and specificity was 100% (1-sided 95% CI, 97.5%). Hypothermic dogs had a median RAG of 0.2°C (0.4°F, range, −1.3° to 0.8°C [−2.4° to 1.5°F]). The sensitivity for detection of hypothermia with axillary temperature was 86% (95% CI, 42% to 99%), and specificity was 87% (95% CI, 76% to 94%).

None of the assessed physical examination or coat variables were significantly associated with RAG (Table 1). Neither shock as defined by the attending clinician (n = 4; P = 0.30) nor hyperdynamic findings (9; P = 0.30) were correlated with RAG.

Table 1—

P values for correlations between RAG versus signalment and other variables in 94 dogs and 31 cats.

VariableDogsCats
Sex0.090.23
Weight0.10.004
BCS0.170.02
Coat length0.240.68
Coat density0.640.57
Hair length in axilla0.970.45
Mucous membrane color0.780.72
Capillary refill time0.850.53
Pulse quality0.570.41
Mentation0.960.21
Heart rate0.260.94
Blood pressure0.260.56
Blood lactate concentration0.710.62
Diarrhea0.34NA
Shock0.250.93

NA = Not applicable because of an insufficient number of cats with diarrhea.

Feline data—Thirty-three cats were initially included in the study, but 2 cats were excluded because of suspected aortic thromboembolism. Therefore, 31 cats were included, of which 17 (55%) were female and 14 (45%) were male. Median age was 8 years (range, 0.2 to 19 years), and median weight was 4.39 kg (9.7 lb; range, 0.6 to 7.9 kg [1.3 to 17.4 lb]). There were 25 domestic shorthairs, 5 domestic longhairs, and 1 Maine Coon cat.

Axillary and rectal temperatures were positively correlated (ρ = 0.75; P < 0.001; Figure 1), and median axillary temperature (38.4°C [101.1°F]; range 33.7° to 40.3°C [92.7° to 104.6°F]) was not significantly (P = 0.381) different from median rectal temperature (38.6°C [101.5°F]; range 33.1° to 40.2°C [91.5° to 104.4°F]). A clinically important amount of variation was found in the limits of agreement (−1.39° to 1°C [−2.5° to 1.8°F]) as determined by Bland-Altman analysis (Figure 2).

The median RAG was 0.2°C (0.3°F; range −1.1° to 1.6°C [−1.9° to 3°F]). Sixty-five percent (20/31) of cats had an RAG ≤ 0.5°C. Fifty-five percent (17/31) of cats had a positive RAG (rectal temperature greater than axillary temperature), 6% (2/31) had equal temperatures, and 39% (12/31) had a negative RAG (rectal temperature less than axillary temperature).

Six of 31 (19%) cats were hyperthermic and 5 of 31(16%) were hypothermic on the basis of rectal temperature. In the hyperthermic population, median RAG was 1.0°C (1.8°F; range, −0.1° to 1.6°C [−0.2° to 3°F]). Sensitivity for detection of hyperthermia for axillary temperature was 33% (95% CI, 7% to 93%), and specificity was 100% (1-sided 95% CI, 97.5%). In the hypothermic cats, the median RAG was −0.1°C (−0.2°F; range −0.7° to 0.6°C [−1.2° to 1.1°F]). Sensitivity for detection of rectal hypothermia with axillary temperature was 80% (95% CI, 28% to 99%), and specificity was 96% (95% CI, 80% to 99%).

Among the physical examination variables, weight (ρ = 0.514; P = 0.004) and BCS (ρ = 0.431; P = 0.018; Figure 3) were significantly associated with RAG. All other evaluated variables were not associated with RAG (Table 1). There were insufficient numbers of affected cats to separately evaluate cats with shock or those with hyperdynamic findings.

Figure 3—
Figure 3—

Scatterplot of RAG versus BCS in 31 cats.

Citation: Journal of the American Veterinary Medical Association 244, 10; 10.2460/javma.244.10.1170

Discussion

Results of this study indicated that there was a large variation in axillary temperature, compared with rectal temperature. Although the median temperature difference (RAG) was acceptable (0.38°C [0.7°F] in dogs, 0.17°C in cats), only 64% of dogs and 65% of cats had an RAG that was considered acceptable (≤ 0.5°C). Because of the large amount of variation in RAG, a correction factor could not be calculated for axillary temperature, and axillary temperature was not considered to be a reliable surrogate for rectal temperature in dogs and cats.

Axillary temperature had high specificity (100%) for detecting hyperthermia (defined on the basis of rectal temperature) in both dogs and cats. Although all animals in this study with increased axillary temperature were truly hyperthermic, axillary temperature should only be used as a screening test for hyperthermia with caution because the sensitivity for detection of hyperthermia was only 57% in dogs and 33% in cats. In other words, our results suggested that animals with a high axillary temperature are most likely truly hyperthermic (as determined by a rectal temperature measurement), but an axillary temperature within reference range does not rule out the possibility of hyperthermia. In humans, increased core body temperature leads to an increase in the variability of axillary temperature.9,24 This was also true in cats in the present study because the hyperthermic group had an RAG of 1.0°C, compared with the overall mean of 0.17°C.

Axillary temperature had a moderately high sensitivity and specificity for detection of hypothermia in dogs (86% and 87%, respectively) and cats (80% and 96%, respectively). This suggests that animals with axillary temperatures in the normothermic range are unlikely to be truly hypothermic, but an axillary temperature in the hypothermic range does not rule out normothermia (as indicated by the rectal temperature).

Of the evaluated physical examination variables, a significant correlation to RAG was found with both body weight and BCS in cats. Cats with greater weight and BCS had a greater RAG, whereas cats with a lower BCS were more likely to have a smaller RAG and thus increased accuracy of the axillary temperature. Interestingly, a greater variation in RAG has also been found in humans with higher BCSs.14 This finding may be related to differences in distribution of body fat in the axilla. An increased amount of axillary fat may lead to insulation of the thermometer probe from the core body temperature and thus a greater variation in RAG. A prior study2 found a larger variation in the RAG in larger dogs, but less variation in RAG in overweight dogs.2 This may be attributable to the greater natural variation in the overall size and body conformation of dogs, compared with cats, which might result in a greater RAG. A larger sample population may help to elucidate any association between weight and BCS with RAG in dogs.

No significant difference in RAG was found in dogs with shock, compared with dogs without shock. In humans, the gradient between core and peripheral temperature increases with shock,26,27 and monitoring the temperature gradient is a useful clinical tool in evaluating treatment and resolution of shock. In the present study, the lack of a significant difference in RAG between dogs with and without shock may have been associated with the small sample size of dogs with shock as well as the clinician-dependent definition of shock. Further investigation is needed to determine whether the RAG may be useful in assessment of dogs with critical illness and shock.

It has been suggested that axillary temperature is expected to be lower than rectal temperature,1 yet 14% of dogs and 39% of cats had a higher axillary temperature in the present study. Although animals with known axillary or rectal lesions that may have affected temperature measurements were excluded from this study, it is possible that the presence of unidentified lesions contributed to these findings. Although rectal temperature was used as the gold standard for core body temperature in this study because its measurement is minimally invasive, its use is standard in veterinary practice, and it is the most accurate minimally invasive estimation of core body temperature in dogs29 and humans,14,22 it may not be reflective of core temperature in all animals. Rectal temperature measurements can be affected by fecal material, rectal inflammation, thrombotic conditions,29 peristalsis, muscle tone, and physical activity30; if some of these variables caused lower rectal temperatures in the animals in our study, the result may have been the higher axillary temperatures found in some animals. Rectal temperature also lags behind changes in core body temperature in humans14,31 by a mean of 15 minutes (range, 10 to 40 minutes),32 and a greater variation in RAG occurs at the onset of hyperthermia in humans, compared with RAG determined when hyperthermia is established.4 In 1 canine study,30 rectal temperature was higher than pulmonary artery temperature in 63.6% of readings. Comparison of axillary temperature to a more reliable measurement of core body temperature (such as pulmonary artery temperature) would be ideal, although this would be invasive to perform and was impractical for the scope of this study.

In this study, data collection was performed by multiple personnel including clinicians, nursing staff, and veterinary students; this may have increased variation in the data, although a standardized method of obtaining temperatures was taught to all participants. Nevertheless, the manner in which the study was performed accurately reflected use of personnel in clinical practice. Additionally, the heterogeneous animal population (including animals of all ages, sizes, breeds, and health status) may have reduced the ability to detect small differences between each type of animal.

Environmental factors such as temperature of the room, time of day, amount of animal bedding, and IV fluid infusion were not evaluated in this study. The time of day at which the temperature is measured has been associated with differences between rectal and axillary temperatures in a human study24 and may have been associated with the RAG in the present study. The limb of IV catheter placement and fluid administration was also not noted during the present study. However, in human neonates, IV fluid administration does not affect axillary temperature.3 This variable has not been investigated in veterinary patients.

Results suggested that although measurement of axillary temperature is convenient in animals, it does not reliably reflect rectal temperature in dogs and cats and should not be used as a replacement for rectal temperature. Further studies are needed to investigate the accuracy of axillary temperature in certain patient populations, such as patients with low BCSs.

ABBREVIATION

BCS

Body condition score

CI

Confidence interval

RAG

Rectal-axillary gradient

a.

BD Basic Digital Thermometer, 3M Consumer Healthcare, Saint Paul, Minn.

b.

Stata, version 12.0 for Mac, Stata Corp, College Station, Tex.

References

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  • Figure 1—

    Scatterplots of paired rectal and axillary temperatures in 94 dogs (A) and 31 cats (B).

  • Figure 2—

    Bland-Altman plots of the agreement between paired rectal and axillary temperatures in 94 dogs (A) and 31 cats (B).

  • Figure 3—

    Scatterplot of RAG versus BCS in 31 cats.

  • 1. Miller JB. Hyperthermia and fever. In: Silverstein D, Hopper K, eds. Small animal critical care medicine: St Louis: Saunders Elsevier, 2009;21.

    • Search Google Scholar
    • Export Citation
  • 2. Lamb V, McBrearty AR. Comparison of rectal, tympanic membrane and axillary temperature measurement methods in dogs. Vet Rec 2013; 173: 524528.

  • 3. Abrams L, Buchholz C, McKenzie NS, et al. Effect of peripheral i.v. infusion on neonatal axillary temperature measurement. Pediatr Nurs 1989; 15: 630632.

    • Search Google Scholar
    • Export Citation
  • 4. Anagnostakis D, Matsaniotis N, Grafakos S, et al. Rectal-axillary temperature difference in febrile and afebrile infants and children. Clin Pediatr (Phila) 1993; 32: 268272.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5. Barringer LB, Evans CW, Ingram LL, et al. Agreement between temporal artery, oral, and axillary temperature measurements in the perioperative period. J Perianesth Nurs 2011; 26: 143150.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6. Chaturvedi D, Vilhekar KY, Chaturvedi P, et al. Comparison of axillary temperature with rectal or oral temperature and determination of optimum placement time in children. Indian Pediatr 2004; 41: 600603.

    • Search Google Scholar
    • Export Citation
  • 7. Craig JV, Lancaster GA, Williamson PR, et al. Temperature measured at the axilla compared with rectum in children and young people: systematic review. BMJ 2000; 320: 11741178.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8. Erickson RS, Kirklin SK. Comparison of ear-based, bladder, oral, and axillary methods for core temperature measurement. Crit Care Med 1993; 21: 15281534.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9. Falzon A, Grech V, Caruana B, et al. How reliable is axillary temperature measurement? Acta Paediatr 2003; 92: 309313.

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