ASPAN's evidence-based clinical practice guideline for the promotion of perioperative normothermia

Effects of Short Preoperative Warming Time on Transurethral Lithotripsy Surgery: A Randomized Controlled Trial

PURPOSE

Preoperative warming prevents inadvertent perioperative hypothermia (IPH). The aim of this study was to investigate the effect of preoperative warming (prewarming) on patient thermal protection and to explore the appropriate duration of preoperative warming for clinical practice.

DESIGN

Randomized controlled clinical trial.

METHODS

117 urological patients were randomized into no prewarming (NP), prewarming 15 minutes (P-15), and prewarming 30 minutes (P-30) groups. Patients' core temperature was monitored and the incidence of IPH, incidence of postoperative shivering, extubation time, length of stay in the postanesthesia care unit, and length of stay in hospital were recorded. The Consolidated Standards of Reporting Trials (CONSORT) checklist was followed.

FINDINGS

The intraoperative core temperature at all time points and the rise in temperature before induction of anesthesia were higher in the P-15 and P-30 groups than in the NP group, but there was no statistically significant difference between the P-15 and P-30 groups. The incidence of IPH was lower in the P-15 (33.3%) and P-30 (37.8%) groups than in the NP group (65.8%), but there was no statistically significant difference between the P-15 and P-30 groups. The incidence of shivering, extubation time, length of stay in the postanesthesia care unit, and length of stay in hospital did not differ between groups.

CONCLUSIONS

Prewarming can effectively maintain intraoperative core temperature in patients undergoing transurethral lithotripsy, and reduce the incidence of IPH. Prewarming 15 minutes before surgery can achieve beneficial clinical effects.

Strategies for perioperative hypothermia management: advances in warming techniques and clinical implications: a narrative review

Perioperative hypothermia is a frequent clinical complication resulting from the cold environment of the operating room and prolonged skin exposure, leading to adverse outcomes and increased healthcare burdens. To address this issue, this narrative review discusses in detail the currently common warming strategies for perioperative hypothermia .Forced air warming (FAW) systems are widely recognized as the most effective intervention for maintaining core body temperature. Additionally, alternative technologies, such as circulating-water mattresses, carbon-fiber resistive heating systems, self-regulated heated air garments, self-heating blankets, and chemical heat packs, offer diverse advantages and disadvantages. Passive warming methods, including thermal reflective blankets and cotton blankets, provide a cost-effective solution, albeit with reduced efficacy compared to active warming measures. Recent advancements have focused on improving both active and passive warming approaches to balance effectiveness and cost-efficiency. While FAW remains the gold standard, other systems offer specific benefits, such as improved portability and reduced costs, making them suitable for use in diverse clinical scenarios. Effective perioperative temperature management reduces hypothermia-related complications, decreases healthcare expenditures, and provides substantial social and organizational benefits. Thus, selecting the most appropriate warming intervention in clinical practice requires a tailored approach, considering both patient-specific needs and resource availability.

Barriers and Solutions in Implementing Evidence-Based Recommendations to Prevent Intraoperative Inadvertent Hypothermia: A Qualitative Study

In this study, it was aimed to understand the barriers and solutions for operating room (OR) nurses and anesthesiologists to implement evidence-based recommendations to prevent intraoperative inadvertent hypothermia (IIH). A qualitative, inductive, and descriptive study was conducted. This qualitative interview study was conducted face-to-face with 19 participants working in OR units between February and March 2023. The interviews were analyzed using qualitative content analysis. The COREQ checklist was followed. Two main themes and five sub-themes were identified as a result of content analysis. According to the participants, barriers to IIH prevention interventions are caused by individual and organizational inefficiencies and personal opinions, and the main solution is education. Participants reported many factors that hinder IIH prevention practices. The individual characteristics of OR staff and the opinions and behavior of the institution are very important for IIH prevention.

Effects of Active Heating Methods on Body Temperature, Shivering, Thermal Comfort, Pain, Nausea and Vomiting During General Anesthesia: A Randomized Controlled Trial

To investigate the effect of forced-air warming and heated intravenous (IV) and irrigation fluids alone and in combination on body temperature, shivering, thermal comfort, pain, nausea and vomiting in adult patients undergoing surgery under general anesthesia in a prospective, four-group, randomized controlled trial. After induction of anesthesia, 120 patients were divided into the following groups: patients warmed with forced-air warming (n = 30), patients receiving warmed IV and irrigation fluid (n = 30), patients receiving warmed IV and irrigation fluid with forced-air warming (n = 30), and the control group without any intervention (n = 30). Body temperature, shivering, thermal comfort, pain, nausea and vomiting were monitored in the first 24 hours after surgery. The general characteristics of the groups, mean body temperature, length of stay, ambient temperature, and duration of surgery in the preoperative waiting unit were similar (p > 0.05). Compared with the other groups, patients in the control group had a significant decrease in body temperature from the 30th minute during surgery (p < 0.001), lower body temperature in the first 2 hours and thermal comfort in the first three hours after surgery (p < 0.01), and higher shivering levels in the first hour after surgery (p < 0.01). There was no significant difference between the groups in terms of postoperative pain, nausea and vomiting (p > 0.05). The study findings showed that normothermia was maintained in all three intervention groups during the surgery and in the first 24 hours after surgery. Moreover, postoperative thermal comfort increased and shivering levels decreased compared with the control group, but pain, nausea and vomiting levels were not affected. The study was registered on ClinicalTrials.gov (NCT04907617).

Evaluation of the Effect of Surgical Drapes on Intraoperative Hypothermia: A Randomized Clinical Trial

Many patients experience unintended hypothermia in intraoperative processes. This randomized clinical trial aims to investigate the impact of surgical drapes on hypothermia during the intraoperative period. A randomized clinical trial was conducted from April 2019 to November 2020 in the Department of Anesthesiology and Reanimation/Operating Rooms at an education and research hospital. Out of 205 patients assessed for eligibility, 74 underwent elective abdominal surgery and were randomized into two groups: nonwoven surgical drapes and woven surgical drapes. The study had two stages: preoperative and intraoperative. Preoperative data were collected using information and evaluation forms, while intraoperative assessment involved forms for wetness and weight. Tympanic and esophageal temperatures were recorded every 15 minutes, and surgical drapes were weighed with a precision scale before and after surgery. There was no significant difference between the two groups in terms of body mass index, irrigation amount, surgery duration, gender, and preoperative shivering (p > 0.05). A statistically significant difference was found in preoperative body temperature (36°C), type of surgery, and intraoperative hypothermia (p < 0.05). Both types of surgical drapes were wet, but this difference was not statistically significant between the nonwoven group (mean ± SD [1368 ± 607]) and the woven group (mean ± SD [1335 ± 636], p = 0.824). This study demonstrated that neither woven nor nonwoven surgical drapes, nor the wetness of the surgical drapes, had a significant effect on intraoperative hypothermia. However, there is a need for randomized controlled trials involving uniform types of surgery related to the topic.

Effects of different forced-air warming systems on the core temperature of patients: a manikin and multi-center clinical study

BACKGROUND

The use of forced-air warming (FAW) blankets is widely recognized for preventing shivering and hypothermia in patients under general anesthesia. Various types of products are currently available for hospitals, and we have conducted a preliminary evaluation of insulation equipment based on expert opinions and initial parameters. However, we lack real-world experiments and accurate clinical data to validate these parameters and the accuracy of our decision-making results. This study aims to confirm the effectiveness of different FAW systems by assessing the thermal protection and operational characteristics of the equipment in both experimental and clinical settings, thereby enhancing our evaluation database.

METHODS

In the manikin test, we conducted six tests including heat distribution and heating rate, heater outlet temperature stability, etc. In the clinical study, patients were randomly assigned to four groups [Group A (Bair Hugger Therapy, 3 M, St. Paul, MN, USA; 63500); Group B (EQUATOR® level I, Smith Medical ASD, MN, USA; Snuggle Warm, SW-2013); Group C (Jiang Men Da Cheng Medical Devices Co., Ltd, China; IOB-006); and Group D (Shang Hai Nest Tech Medical Materials Co., Ltd, China; BH-017)], with each group comprising 30 individuals. At the start of anesthesia induction, the FAW blanket was activated and set to 43 °C until the completion of surgery. The primary endpoint was the average core body temperature during surgery. Secondary endpoints included hemodynamic and surgical variables, adverse events, and recovery metrics.

RESULTS

In the manikin test, the observed results of the experimental parameters (heat distribution, air pressure difference, and hole observation test) for Group A are superior to those of the other groups. In the clinical study, although the mean perioperative core body temperature remained above 36 °C across all groups [Group A: 36.31 ± 0.04; Group B: 36.26 ± 0.06; Group C: 36.17 ± 0.03; Group D: 36.25 ± 0.05], patients in Group A maintained higher temperatures compared to the other groups (p < 0.001).

CONCLUSIONS

Among patients undergoing laparoscopic radical resection of colorectal cancer with general anesthesia, all four FAW systems effectively prevented perioperative hypothermia. However, the system in Group A minimized heat loss more effectively than the others, providing superior thermal protection.

TRIAL REGISTRATION

ChiCTR2200065394, 03/11/2022.

Clinical application of multidisciplinary team- and evidence-based practice project in gynecological patients with perioperative hypothermia

BACKGROUND

Perioperative hypothermia (PH) negatively affects the physical and mental health of patients to varying degrees. Currently, there is no effective multidisciplinary team (MDT) intervention for gynecological patients with PH.

AIM

To apply the best evidence on the prevention and management of PH in gynecological patients, improve the quality of perioperative evidence-based care based on treatment by an MDT for gynecological patients and analyze the effect of MDT- and evidence-based practice (EBP) projects on the psychological status and cognitive function of gynecological patients with PH.

METHODS

Under the guidance of knowledge translation and combined with the opinions of involved stakeholders and clinical experts, the best evidence for PH prevention and management in gynecological patients was selected and adjusted to suit the practice setting. Based on the evidence, the practice plan was developed, and the MDT intervention was carried out in the preoperative ward, the preoperative preparation room, the intraoperative operating room, the postanesthesia care unit, and the 24-hour postoperative gynecological ward through the EBP program. The incidence of hypothermia, the nurses’ awareness, the implementation rate of examination indicators, and the thermal comfort level, psychological status and cognitive function of patients were compared before and after the implementation of the program.

RESULTS

The incidence of PH in gynecological patients decreased from 43.33% to 13.33% after the implementation of the scheme. The implementation rate of examination indicators 6-10, 12, 14, 16-18, 21, and 22 reached 100%, and that of other indicators was above 90%, except for examination indicators 5 and 13, which was 66.67%; the indices were significantly improved compared with the baseline (before evidence application) (P < 0.05). The score of nurses' awareness of PH prevention and management in gynecological patients increased from 60.96 ± 9.70 to 88.08 ± 8.96, and the difference was statistically significant (P < 0.001). The total score of the perioperative thermal comfort level of patients undergoing gynecological surgery was 27.97 ± 2.04, which was significantly increased compared with the score of 21.27 ± 1.57 observed by researchers at baseline (P < 0.001). The perioperative Hamilton Depression Scale and Hamilton Anxiety Scale scores of patients undergoing gynecological surgery decreased from 15.03 ± 3.16 and 13.93 ± 2.64 to 4.30 ± 1.15 and 3.53 ± 0.78, respectively, with statistically significant differences (P < 0.001). The perioperative Montreal Cognitive Assessment Scale score of the gynecological surgery patients increased from 23.17 ± 1.68 to 26.93 ± 1.11, also with statistical significance (P < 0.001).

CONCLUSION

MDT-based EBP for PH prevention and management in gynecological patients during the perioperative period can standardize nursing operations, improve nurses' awareness and behavioral compliance with gynecological hypothermia management, and reduce the occurrence of PH in gynecological patients while playing a positive role in reducing patients’ negative emotions and enhancing their cognitive function.

Nurse anesthetists' perceptions of heat conservation measures in connection with surgery - a phenomenographic study

BACKGROUND

To minimize the risk of perioperative hypothermia, it is recommended that healthcare professionals be familiar with heat conservation measures and use passive and active warming methods, in line with international guidelines. However, there is a low level of adherence perioperatively to the use of heat conservation measures. To understand why, there is a need to capture the nurse anesthetists' perspective. The aim is to describe nurse anesthetists' perceptions of heat conservation measures in connection with surgery.

METHODS

An inductive descriptive design with a phenomenographic approach was chosen. A total of 19 nurse anesthetists participated and were interviewed. Data were analyzed according to Larsson and Holmström's phenomenographic seven-step model.

RESULTS

Six ways of understanding the phenomenon heat conservation measures in connection with surgery were found: the preventive, the useable, the untenable, the caring, the adaptive, and the routine care approach. These approaches were related to each other in a flexible way, allowing for several to co-exist at the same time, depending on the situation.

CONCLUSIONS

Nurse anesthetists want to prevent the patients' heat loss and maintain normothermia, regardless of the type of surgery. This willingness, motivation, and intention enable the use of heat conservation measures. However, there are perceptions that have an impact, such as doubts and uncertainty, access, time and financial constraints, preconditions, routines or habits, and lack of availability of education/training. These barriers will require support from an organizational level to promote lifelong education and guidelines. As well as offer education at the nurse anesthetists' program.

Development of a perioperative thermal insulation system: Testing comfort properties for different textile sets

The poorly physical and psychological conditions of the patients make the body thermal protection crucial in the perioperative context, due to the risk of hypothermia. The lack of evidence regarding the effectiveness of textile coverings in protecting patients in the operating room, underscores the recommendation of the forced warming system using non-woven fabric for ensuring the best thermal protection in the perioperative context. This study is part of a development process of a three-layered thermal insulation system, a blanket for use in the perioperative context. After previous selection of two fabrics for the mid and outer layers, in this study three fabric samples for the inner layer with same soft tactile sensation and different textile compositions were tested to find its effect on increasing the thermal insulation of the whole set, using a thermal manikin. The serial method was used to calculate the thermal insulation properties of the sets. The best thermal insulation and thermal comfort performance was obtained by the set using an inner layer composed of polypropylene, polyamide, and elastane whose results were the highest thermal conductivity and thickness and the lowest maximum stationary heat flow density. The results indicated that this fabric influenced positively the values of the whole set once increased its thermal protection effectiveness when compared to the other tested sets. This set is more suitable for future testing in patients during their stay in the perioperative setting.

Comparative Efficacy of Six Active Warming Systems for Intraoperative Warming in Adult Patients Undergoing Laparoscopic Surgery: A Systematic Review and Network Meta-Analysis

Intraoperative hypothermia is very common and harmful in adult patients undergoing laparoscopic surgery. A variety of active warming systems has received close attention and has been researched by related scholars. However, the relative efficacy of these systems and which active warming system is preferred for such patients remain unclear. The aim of this study was to compare and rank six active warming systems regarding intraoperative warming efficacy in adult patients undergoing laparoscopic surgery. Following the PRISMA 2020 guidelines, relevant randomized controlled trials (RCTs) on the efficacy of different active warming systems in warming adult patients undergoing laparoscopic surgery were searched from five English databases and three Chinese databases. The quality of the studies was assessed using the Cochrane Risk of Bias tool (RoB2). The outcome was the final intraoperative core temperature. We estimated direct effects by using pairwise meta-analysis, estimated relative effects and ranking with the consistency model to conduct an NetworkMeta-Analysis (NMA). We used GRADE (Grading of Recommendations Assessment, Development, and Evaluation) to assess the certainty of the evidence. Sensitivity analysis was performed to test the robustness of the results. This study is registered with PROSPERO, with number CRD42022309057. In total, 19 RCTs involving 6 active warming systems and comprising 1364 patients were included in this NMA. The NMA once again confirmed the validity of forced-air warming (FAW) systems compared with other active warming systems, and further showed that underbody FAW was associated with more remarkable warming efficacy in different types of FAW systems. NMA was used to perform an exhaustive comparison of the warming efficacy of six active warming systems and indicated that underbody FAW was most likely to be the most effective warming system in adult patients undergoing laparoscopic surgery; however, considering the sparsity of the network, our results should be cautiously interpreted. Furthermore, a large number of high-quality RCTs comparing the warming efficacy of different competitive active warming systems are needed.

Çocuk Hastanesinde Perioperatif Hipotermi Sıklığı ve Predispozan Faktörler

Background/Aim: Perioperative hypothermia is more common in pediatric patients than in adult patients due to increased body surface area/weight ratio and limited subcutaneous fat deposits. Therefore, active and passive warming techniques are used more frequently in the surgeries applied to pediatric patients. This study presents the prevalence of perioperative hypothermia and the predisposing conditions for perioperative hypothermia in pediatric orthopedic surgeries in which active and passive warming techniques are applied. Methods: This cross-sectional, descriptive, and observational study included 102 children admitted to the pediatric orthopedic clinic of a children’s hospital. Temperature measurements were made with a calibrated infrared tympanic thermometer in all cases while they were waiting in the service room, when they entered the operation theater, when they left the operation theater, and when they left the postoperative care unit. Their demographic data, hemogram, and thyroid hormone parameters, preoperative fasting times related to the procedure, and temperature were recorded. Also, the humidity and temperature values of the operating theater, the operation type performed, the anesthesia method applied during the operation, the complications encountered, and the time spent in the operating theater were all recorded in their follow-up forms. Data analysis was done using SPSS V21.0 and was conducted at a 95% confidence interval. Results: Hypothermia was observed in 20,58% of 102 patients included in the study. Predisposing factors were determined for perioperative hypothermia as follows; the patient's American Society of Anesthesiologists risk score is above 1, concomitant diagnosis of cerebral palsy, low hemoglobin level in the preoperative period, fasting longer than 8 hours, the low body temperature of the patient in the service room, long time stayed in the operating room, and different humidity values of the operating theatre. Conclusion: Although active and passive warming techniques are applied during the operation, perioperative hypothermia was observed in 20,58% of pediatric patients who underwent the orthopedic operation. Consideration of predisposing factors together with active and passive warming techniques may reduce the incidence of perioperative hypothermia.

An Overview of the Implications for Perianesthesia Nurses in terms of Intraoperative Changes in Temperature and Factors Associated with Unintentional Postoperative Hypothermia

Patients undergo surgery and anaesthesia on a daily basis across the United States and throughout the world. A major source of worry for these patients continues to be inadvertent hypothermia, once core temperature <36°C (96.8°F). Despite well-documented adverse physiological consequences, anaesthesia nurses continue to have a difficult task in keeping patient warmth pre-/peri-/post-surgical procedure. Thermostasis within postoperative patient necessitates the collaboration of many individuals. In order to provide safe and high-quality treatment, it is essential to use the most up-to-date data to guide therapeutic procedures targeted at achieving balance body temperature in surgical patients. Providing a review of the physiology of perioperative temperature variations and the comorbidities linked with accidental intraoperative hypothermia, this article will also provide preventive and treatment methods.

Determining the Effectiveness of Forced-Air Warming Blankets in Maintaining Postoperative Body Temperature: A Randomized Controlled Trial

PURPOSE

The aim of this study is to determine the effectiveness of forced-air warming blankets in normalizing body temperature in the postoperative period.

DESIGN

Randomized controlled trial METHODS: The study sample consisted of patients (N = 67) who underwent lung lobectomy in the Thoracic Surgery Service of a university hospital. Forced-air warming blankets were used in the treatment group and 100% cotton blankets were used in the control group. Patients' body temperatures were monitored using a tympanic thermometer until it reached 37°C.

FINDINGS

The body temperature of the patients in the treatment group reached 37°C in a shorter time than that of the patients in the control group (52.27 ± 29.79 min and 139.0 ± 81.93 min, respectively; P < .001), and that the perception of comfort of the patients in the treatment and control groups increased (P < .001) after warming.

CONCLUSIONS

We recommend that forced-air warming blankets are used for patients undergoing lung lobectomy in order to reach normal body temperature in a shorter time.

Patients experience of warmth and coldness in connection with surgery - a phenomenological study

Purpose: The aim was to describe patients' lived experience of warmth and coldness in connection with surgery. Methods: A reflective lifeworld research (RLR) approach founded on phenomenology and the methodological principles of openness, flexibility, and bridling were used. The data consisted of 16 in-depth interviews with patients from four hospitals in Sweden. Results: Warmth and coldness in connection with surgery means an expectation to maintain one´s daily life temperature comfort. When patients' needs of temperature comfort is fulfilled it give a sense of well-being and calmness. Despite the body is covered there are feelings of vulnerability. When patients have the ability to change their own temperature comfort, they feel independent. Conclusion: The individual feeling of temperature comfort could be affected or changed to discomfort during the perioperative context, and an intervention is required to avoid suffering due to the care. An ability to independently influence one´s own temperature comfort can strengthen the patient, whereas the opposite entails suffering in silence. The phenomenon is also related to feelings of confidence about receiving the best care as well as being exposed and vulnerable. When the patient´s need of comfortable temperature is met then feelings of security and sense of well-being emerged.

Effect of prewarming on body temperature in short-term bladder or prostatic transurethral resection under general anesthesia: A randomized, double-blind, controlled trial

Perioperative hypothermia causes postoperative complications. Prewarming reduces body temperature decrease in long-term surgeries. We aimed to assess the effect of different time-periods of prewarming on perioperative temperature in short-term transurethral resection under general anesthesia. Randomized, double-blind, controlled trial in patients scheduled for bladder or prostatic transurethral resection under general anesthesia. Eligible patients were randomly assigned to receive no-prewarming or prewarming during 15, 30, or 45 min using a forced-air blanket in the pre-anesthesia period. Tympanic temperature was used prior to induction of anesthesia and esophageal temperature intraoperatively. Primary outcome was the difference in core temperature among groups from the induction of general anesthesia until the end of surgery. Repeated measures multivariate analysis of covariance modeled the temperature response at each observation time according to prewarming. We examined modeled contrasts between temperature variables in subjects according to prophylaxis. We enrolled 297 patients and randomly assigned 76 patients to control group, 74 patients to 15-min group, 73 patients to 30-min group, and 74 patients to the 45-min group. Temperature in the control group before induction was 36.5 ± 0.5 °C. After prewarming, core temperature was significantly higher in 15- and 30-min groups (36.8 ± 0.5 °C, p = 0.004; 36.7 ± 0.5 °C, p = 0.041, respectively). Body temperature at the end of surgery was significantly lower in the control group (35.8 ± 0.6 °C) than in the three prewarmed groups (36.3 ± 0.6 °C in 15-min, 36.3 ± 0.5 °C in 30-min, and 36.3 ± 0.6 °C in 45-min group) (p < 0.001). Prewarming prior to short-term transurethral resection under general anesthesia reduced the body temperature drop during the perioperative period. These time-periods of prewarming also reduced the rate of postoperative complications.Study Registration Registered at ClinicalTrials.gov (Identifier: NCT03630887).

Perioperative Hypothermia-A Narrative Review

Unintentional hypothermia (core temperature < 36 °C) is a common side effect in patients undergoing surgery. Several patient-centred and external factors, e.g., drugs, comorbidities, trauma, environmental temperature, type of anaesthesia, as well as extent and duration of surgery, influence core temperature. Perioperative hypothermia has negative effects on coagulation, blood loss and transfusion requirements, metabolization of drugs, surgical site infections, and discharge from the post-anaesthesia care unit. Therefore, active temperature management is required in the pre-, intra-, and postoperative period to diminish the risks of perioperative hypothermia. Temperature measurement should be done with accurate and continuous probes. Perioperative temperature management includes a bundle of warming tools adapted to individual needs and local circumstances. Warming blankets and mattresses as well as the administration of properly warmed infusions via dedicated devices are important for this purpose. Temperature management should follow checklists and be individualized to the patient's requirements and the local possibilities.

Perioperative temperature management: a survey of 6 Asia-Pacific countries

BACKGROUND

Anesthesia leads to impairments in central and peripheral thermoregulatory responses. Inadvertent perioperative hypothermia is hence a common perioperative complication, and is associated with coagulopathy, increased surgical site infection, delayed drug metabolism, prolonged recovery, and shivering. However, surveys across the world have shown poor compliance to perioperative temperature management guidelines. Therefore, we evaluated the prevalent practices and attitudes to perioperative temperature management in the Asia-Pacific region, and determined the individual and institutional factors that lead to noncompliance.

METHODS

A 40-question anonymous online questionnaire was distributed to anesthesiologists and anesthesia trainees in six countries in the Asia-Pacific (Singapore, Malaysia, Philippines, Thailand, India and South Korea). Participants were polled about their current practices in patient warming and temperature measurement across the preoperative, intraoperative and postoperative periods. Questions were also asked regarding various individual and environmental barriers to compliance.

RESULTS

In total, 1154 valid survey responses were obtained and analyzed. 279 (24.2%) of respondents prewarm, 508 (44.0%) perform intraoperative active warming, and 486 (42.1%) perform postoperative active warming in the majority of patients. Additionally, 531 (46.0%) measure temperature preoperatively, 767 (67.5%) measure temperature intraoperatively during general anesthesia, and 953 (82.6%) measure temperature postoperatively in the majority of patients. The availability of active warming devices in the operating room (p < 0.001, OR 10.040), absence of financial restriction (p < 0.001, OR 2.817), presence of hospital training courses (p = 0.011, OR 1.428), and presence of a hospital SOP (p < 0.001, OR 1.926) were significantly associated with compliance to intraoperative active warming.

CONCLUSIONS

Compliance to international perioperative temperature management guidelines in Asia-Pacific remains poor, especially in small hospitals. Barriers to compliance were limited temperature management equipment, lack of locally-relevant standard operating procedures and training. This may inform international guideline committees on the needs of developing countries, or spur local anesthesiology societies to publish their own national guidelines.

Optimal Application of Forced Air Warming to Prevent Peri-Operative Hypothermia during Abdominal Surgery: A Systematic Review and Meta-Analysis

Patients who undergo abdominal surgery under general anesthesia develop hypothermia in 80–90% of the cases within an hour after induction of anesthesia. Side effects include shivering, bleeding, and infection at the surgical site. However, the surgical team applies forced air warming to prevent peri-operative hypothermia, but these methods are insufficient. This study aimed to confirm the optimal application method of forced air warming (FAW) intervention for the prevention of peri-operative hypothermia during abdominal surgery. A systematic review and meta-analysis were conducted to provide a synthesized and critical appraisal of the studies included. We used PubMed, EMBASE, CINAHL, and Cochrane Library CENTRAL to systematically search for randomized controlled trials published through March 2020. Twelve studies were systematically reviewed for FAW intervention. FAW intervention effectively prevented peri-operative hypothermia among patients undergoing both open abdominal and laparoscopic surgery. Statistically significant effect size could not be confirmed in cases of only pre- or peri-operative application. The upper body was the primary application area, rather than the lower or full body. These findings could contribute detailed standards and criteria that can be effectively applied in the clinical field performing abdominal surgery.

Short-Periods of Pre-Warming in Laparoscopic Surgery. A Non-Randomized Clinical Trial Evaluating Current Clinical Practice

Background: Pre-warming prevents perioperative hypothermia. We evaluated the current clinical practice of pre-warming and its effects on temperature drop and postoperative complications; Methods: This prospective, observational pilot study examines clinical practice in a tertiary hospital on 99 patients undergoing laparoscopic urological surgery. Pre-warming was performed in the pre-anesthesia room. Patients were classified into three groups: P 0 (non-prewarmed), P 5–15 (pre-warming 5–15 min) and P > 15 (pre-warming 15–30 min). Tympanic temperature was recorded in the pre-anesthesia room, prior to anesthesia induction, and in the PACU. Esophageal temperature was recorded intraoperatively. The occurrence of shivering, pain intensity, length of stay in PACU, and postoperative complications during hospital stay were also recorded; Results: After pre-warming, between-group difference in body temperature was higher in P > 15 than in P 0 (0.4 °C, 95% CI 0.14–0.69, p = 0.004). Between P 5–15 and P 0 difference was 0.2 °C (95% CI 0.04–0.55, p = 0.093). Temperature at the end of surgery was higher in pre-warmed groups [mean between-group difference 0.5 °C (95% CI 0.13–0.81, p = 0.007) for P 5–15; 0.9 °C (95% CI 0.55–1.19, p < 0.001) for P > 15]. Pain and shivering was less common in pre-warmed groups. Postoperative transfusions and surgical site infections were lower in P > 15; Conclusion: Short-term pre-warming prior to laparoscopic urological surgery decreased temperature perioperative drop and postoperative complications.

The Effect of Active Warming on Postoperative Hypothermia on Body Temperature and Thermal Comfort: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to determine the effect of active warming method in temperature control and thermal comfort in hypothermia after surgery.

DESIGN

A randomized controlled trial.

METHODS

The study sample consisted of 64 male and female postanesthesia care unit and intensive care unit neurosurgery postoperative inpatients. The experimental group was warmed using the active warming method, and the control group's routine care was continued via a cotton blanket. Patients were warmed until their tympanic body temperature reached 37°C.

FINDINGS

The time needed to adequately warm patients was approximately twice as short in those who received active warming as compared with the control group. The perception of thermal comfort was significantly higher in the first hour in patients who received the active warming method (P < .05).

CONCLUSIONS

The active warming method resulted in a shorter time to warming in hypothermia after surgery and an increase in the perception of thermal comfort and body temperature.

Prospective observational study of the effectiveness of prewarming on perioperative hypothermia in surgical patients submitted to spinal anesthesia

Prewarming has been shown to prevent intraoperative inadvertent hypothermia. Nevertheless, data about optimal prewarming-time from published clinical trials report contradictory results. We conducted this pilot study to evaluate routine clinical practice regarding prewarming and its effect on the prevalence of perioperative hypothermia in patients undergoing transurethral resection (TUR) under spinal anesthesia. This was a prospective, observational, pilot study to examine clinical practice in a tertiary hospital regarding prewarming in 140 consecutive patients. When prewarming (pw) was performed, forced-air warming was provided in the pre-anesthesia room for 15 (pw15), 30 (pw30), or 45 (pw45) min. Tympanic temperature was recorded upon entering the pre-anesthesia room, at the time of initiating surgery, and every 15 min intra-operatively. We also recorded duration of the surgical procedure and length of stay in the Post-Anesthesia Care Unit (PACU). Pw15 was performed in 34 patients, pw30 in 29 patients, and pw45 in 21 patients. Fifty-six patients did not receive pw and 96% of them developed hypothermia at the end of the surgical procedure, compared to 73% of patients in pw15 (p = 0.002), 75% in pw30 (p = 0.006) and 90% in pw45 (p = 0.3). Length of stay in the PACU was markedly shorter in pw15 (131 ± 69 min) and pw30 (123 ± 60 min) than in the non-pw group (197 ± 105 min) (p = 0.015 and p = 0.011, respectively). This difference was not significant in pw45 (129 ± 56 min) compared to non-pw patients. In conclusion, prewarming for 15 or 30 min before TUR under spinal anesthesia prevents development of hypothermia at the end of the surgical procedure.

Prevention of inadvertent perioperative hypothermia - Guideline compliance in German hospitals

Patients undergoing elective surgery are at risk for inadvertent postoperative hypothermia, defined as a core body temperature below 36°C. This study was conducted to investigate the acceptance of the recommendations of the German S3 Guideline, in particular with respect to the concept of pre-warming and sublingual temperature measurement. The main focus was to gather data concerning the postoperative core temperature and the frequency of perioperative hypothermia in patients receiving a pre-warming regime and those without. The study team investigated the local concept and measures employed to avoid inadvertent perioperative hypothermia with respect to defined outcome parameters following a specific protocol. In summary, the study hospitals vary greatly in their perioperative processes to prevent postoperative hypothermia. However, each hospital has a strategy to prevent hypothermia and was more or less successful in keeping its patients normothermic during the perioperative process. Our data could not demonstrate major differences between hospitals in the implementation strategy to prevent perioperative hypothermia in regard to the hospital size. The results of our study suggest a wide-spread acceptance, as no postoperative hypothermia was detected in a cohort of 431 patients.

Benefits of Passive Warming on Surgical Patients Undergoing Regional Anesthetic Procedures

PURPOSE

The purpose of this quality improvement project was to determine if application of preoperative passive warming methods would maintain body temperature in patients receiving regional anesthetic procedures (RAPs).

DESIGN

A nonrandomized quasi-experimental design was used.

METHODS

A passive warming trial using a convenience sample of 53 RAP patients warmed with passive measures was compared with data collected from 67 retrospective chart reviews of RAP patients warmed per standard unit policy-typically active forced warm air. Passive measures included a thermal reflective surgical cap and an activated chemical warmer.

FINDINGS

Passive warming methods maintained temperatures throughout the perioperative process. No significant variations in mean temperatures were noted. As age increased, the difference in temperature from admit to transfer to operating room also increased (P = .0182).

CONCLUSIONS

Passive warming is a suitable cost-effective alternative when forced-air warming is not feasible. Additional inquiry into the use of passive warming is warranted.

Efficacy of forced-air warming for preventing perioperative hypothermia and related complications in patients undergoing laparoscopic surgery: A randomized controlled trial

BACKGROUND

Perioperatively, unexpected hypothermia may cause adverse surgical outcomes. However, few studies have explored the efficacy of forced-air warming in patients undergoing laparoscopic surgery.

AIM/OBJECTIVE

To determine the efficacy of forced-air warming for preventing perioperative hypothermia and complications in patients undergoing laparoscopic surgery.

METHODS

A total of 127 participants undergoing laparoscopic thoracic or abdominal surgery were recruited between January and November 2015. Participants were randomly allocated to intervention (forced-air warming, n = 64) and control groups (passive insulation, n = 63). Oesophageal core temperature was measured during surgery, whilst tympanic core temperature was measured every 30 minutes preoperatively and in the postanaesthesia care unit. Levels of shivering and pain, amount of bleeding, and adverse cardiac events were measured before the transfer from the postanaesthesia care unit. The generalized estimating equation was used for data analysis.

RESULTS

The intervention group had better warming efficacy than the control group between 90 and 330 minutes during surgery. The intervention group had fewer complications than the control group in terms of intraoperative bleeding, time to rewarm to 36°C, pain levels, and shivering levels in the postanaesthesia care unit.

CONCLUSION

Forced-air warming can increase warming efficacy and reduce complications of perioperative hypothermia in patients undergoing laparoscopic surgery.

Effectiveness of Early Warming With Self-Warming Blankets on Postoperative Hypothermia in Total Hip and Knee Arthroplasty

BACKGROUND

Hypothermia is an important complication in joint arthroplasty. Commonly, forced air warming (FAW) devices are used intraoperatively to maintain body temperature in patients undergoing surgery. However, it is believed that these convective warming systems could increase the risk of deep surgical site infections due to disruption of unidirectional downward laminar airflow. Conductive warming devices have no noticeable effect on ventilation airflow. Nevertheless, the effectiveness of the self-warming (SW) blanket, a novel conductive warming device, on postoperative hypothermia in elective joint arthroplasty is unknown.

PURPOSE

The purpose of this study was to evaluate the effectiveness of early warming with SW blankets in the prevention of postoperative hypothermia in elective total hip (THA) and knee arthroplasty (TKA) compared with FAW devices.

METHODS

Patients who underwent elective THA or TKA between May and June 2014 were assigned in the FAW or SW group. A total of 105 patients were enrolled into the study. In the FAW group, the FAW devices were applied after disinfection of the surgical site. In the SW group, the SW blankets were already applied in the orthopaedic department. The duration of warming with SW blankets before anesthetic induction was documented. The body temperature was measured preoperatively upon arrival in the orthopaedic department and postoperatively upon arrival in the postanesthesia care unit. The patient's body temperature was measured at the tympanic membrane, and hypothermia was defined as a body temperature of less than 35.5°C.

RESULTS

The SW blankets were applied for a median of 86.8 minutes (78.8-94.8) before anesthetic induction. Postoperative hypothermia was observed in 15 (31.3%) and eight (14.0%) patients in the FAW group and the SW group, respectively (p = .029). The median postoperative body temperature was 35.59°C (35.44-35.74) and 35.95°C (35.83-36.06) in the FAW group and the SW group, respectively (p < .001).

CONCLUSION

Early warming with SW blankets was more effective than FAW devices in the prevention of postoperative hypothermia in elective THA and TKA.

Collaborative Development of a Perioperative Thermal Care Bundle Using the Guideline Implementability Appraisal Tool

BACKGROUND

Perioperative hypothermia significantly increases a patient's risk of adverse complications, such as surgical site infection; morbid cardiac events, and surgical bleeding. Although guideline recommendations are relatively simple and inexpensive, they are often not adhered to in clinical practice. Knowledge tools are tangible resources that assist clinicians to provide evidence-based care.

PURPOSE

This article reports the collaborative development of a knowledge tool-a perioperative thermal care bundle.

DESIGN

Collaborative, iterative design.

METHODS

A multidisciplinary panel of experts used the online GuideLine Implementability Appraisal tool to prioritize and select recommendations for inclusion in the care bundle.

FINDINGS

Through a consensus process, the expert panel selected three main bundle elements: Assess patient's risk of hypothermia and contraindications to active warming; record temperature frequently preoperatively, intraoperatively, and postoperatively; and actively warm, intraoperatively, if they are at high risk, or anytime they are hypothermic.

CONCLUSIONS

The GuideLine Implementability Appraisal tool was a simple yet comprehensive tool that enabled the development of a care bundle by expert clinicians.

Difficult Airway in a Case of Gross Hydrocephalus for Shunt Surgery

Children with gross hydrocephalus for emergency ventriculoperitoneal (VP) shunt present challenges to anesthesiologist due to increase in circumference of head, associated congenital anomalies. Here is a case report of child with gross hydrocephalus with Type 2 Arnold chiari malformation posted for emergency VP shunt placement possessed a difficult airway.

The Nurse Anesthetists' Adherence to Swedish National Recommendations to Maintain Normothermia in Patients During Surgery

PURPOSE

The aim of this study was to determine if nurse anesthetists (NAs) have access, knowledge, and adhere to recommended guidelines to maintain normal body temperature during the perioperative period.

DESIGN

A descriptive survey design.

METHODS

Questionnaires were sent to heads of the department (n = 56) and NAs in the operating departments in Sweden.

FINDING

The level of access to the recommendations is high, but only one third of the operating departments have included the recommendations in their own local guidelines. The NAs' adherence was low, between 5% and 67%, and their knowledge levels were 57% to 60%.

CONCLUSIONS

A high level of knowledge, access, and adherence are important for the organization of operating departments to prevent barriers against implementation of new recommendations or guidelines. There are needs for education about patients' heat loss due to redistribution and clear recommendations.

The Optimal Time and Method for Surgical Prewarming: A Comprehensive Review of the Literature

PURPOSE

Inadvertent hypothermia is a common problem in the operating room. This can contribute to many unfavorable outcomes --rising costs, increased complications, and higher morbidity rates.

DESIGN

This review determined the optimal method and time to prewarm a surgical patient to prevent perioperative hypothermia.

METHODS

CINAHL and PubMed were searched. Fourteen articles were ultimately included in this review.

FINDINGS

Based on the literature reviewed, it was suggested that forced-air warming was most effective in preventing perioperative hypothermia. Eighty-one percent of the experimental studies reviewed found that there was a significantly higher temperature throughout surgery and in the postanesthesia care unit for patients who received forced-air prewarming.

CONCLUSIONS

Thirty minutes was found to be the average suggested amount of time for prewarming among the literature; however, a minimum of 10 minutes of prewarming was suggested to significantly reduce rates of hypothermia in perioperative patients and decrease the adverse effects of hypothermia.

Meta-analysis: effectiveness of forced-air warming for prevention of perioperative hypothermia in surgical patients

AIM

The aim of this study was to evaluate the effectiveness of forced-air warming for preventing perioperative hypothermia.

BACKGROUND

Perioperative hypothermia commonly occurs in patients receiving anaesthesia during surgeries. However, the effectiveness of warming systems requires verification.

DESIGN

Systematic review incorporating meta-analysis.

DATA SOURCES

We searched OVID, PubMed, Cochrane Library, Medline, CINAHL, CETD and CEPS databases (2001-2015) for randomized controlled trials published in English and Chinese. Outcome measures of interests were body temperature and thermal comfort.

REVIEW METHODS

Cochrane methods, Quality of evidence (GRADE) assessments and Jadad Quality Score were used.

RESULTS

Twenty-nine trials (1875 patients) met inclusion criteria, including seven trials (502 patients) related to thermal comfort. Results showed that: (1) forced-air warming was more effective than passive insulation and circulating-water mattresses; (2) there was no statistically significant difference among forced-air warming, resistive heating blankets, radiant warming systems and circulating-water garments; and (3) that thermal comfort provided by forced-air warming was superior to that of passive insulation, resistive heating blankets and radiant warming systems, but inferior to that of circulating-water mattresses.

CONCLUSIONS

Forced-air warming prevents perioperative hypothermia more effectively than passive insulation and circulating-water mattresses, whereas there is no statistically significant difference in its effectiveness compared with circulating-water garments, resistive heating blankets and radiant warming systems.

Forced air warming to maintain normoTHERMIa during SEDation in the cardiac catheterization laboratory: protocol for the THERMISED pilot randomized controlled trial

AIM

To determine whether applying forced air warming attenuates the impact of sedation-induced impairment of thermoregulation on body temperature of patients who are sedated during interventional procedures in the cardiac catheterization laboratory.

BACKGROUND

A moderate proportion of sedated patients who undergo procedures in the cardiac catheterization laboratory with only passive warming become hypothermic. Hypothermia in the surgical population is associated with increased risk of adverse cardiac events, infections, thrombotic and haemorrhagic complications and prolonged hospital stay. For this reason, investigation of the clinical benefits of preventing hypothermia in sedated patients using active warming is required.

DESIGN

Randomized controlled trial.

METHODS

A total of 140 participants undergoing elective interventional procedures with sedation in a cardiac catheterization laboratory will be recruited from two hospitals in Australia. Participants will be randomized to receive forced air warming (active warming) or usual care (passive warming with heated cotton blankets) throughout procedures. The primary outcome is hypothermia (defined as temperature less than 36°C) at the conclusion of the procedure. Secondary outcomes are postprocedure temperature, postprocedural shivering, thermal discomfort, major complications, disability-free survival to 30 days postprocedure, cost-effectiveness and feasibility of conducting a larger clinical trial.

DISCUSSION

The results from this study will provide high-level evidence for practice in an area where there is currently no guidance. Findings will be easily translatable into clinical practice because most hospitals already have forced air warming equipment available for use during general anaesthesia.

REGISTRATION NUMBER

ACTRN12616000013460.

Inadvertent Hypothermia After Procedural Sedation and Analgesia in a Cardiac Catheterization Laboratory: A Prospective Observational Study

OBJECTIVES

To identify the prevalence of and risk factors for inadvertent hypothermia after procedures performed with procedural sedation and analgesia in a cardiac catheterization laboratory.

DESIGN

A single-center, prospective observational study.

SETTING

A tertiary-care private hospital in Australia.

PARTICIPANTS

399 patients undergoing elective procedures with procedural sedation and analgesia were included. Propofol infusions were used when an anesthesiologist was present. Otherwise, bolus doses of either midazolam or fentanyl or a combination of these medications was used.

INTERVENTIONS

None

MEASUREMENTS AND MAIN RESULTS

Hypothermia was defined as a temperature<36.0°C. Multivariate logistic regression was used to identify risk factors. Hypothermia was present after 23.3% (n = 93; 95% confidence interval [CI] 19.2%-27.4%) of 399 procedures. Sedative regimens with the highest prevalence of hypothermia were any regimen that included propofol (n = 35; 40.2%; 95% CI 29.9%-50.5%) and the use of fentanyl combined with midazolam (n = 23; 20.3%; 95% CI 12.9%-27.7%). Difference in mean temperature from pre-procedure to post-procedure was -0.27°C (standard deviation 0.45). Receiving propofol (odds ratio [OR] 4.6 95% CI 2.5-8.6), percutaneous coronary intervention (OR 3.2; 95% CI 1.7-5.9), body mass index<25 (OR 2.5; 95% CI 1.4-4.4) and being hypothermic prior to the procedure (OR 4.9; 95% CI 2.3-10.8) were independent predictors of post-procedural hypothermia.

CONCLUSIONS

A moderate prevalence of hypothermia was observed. The small absolute change in temperature observed may not be a clinically important amount. More research is needed to increase confidence in the authors' estimates of hypothermia in sedated patients and its impact on clinical outcomes.

A systematic review of the effectiveness of warming interventions for women undergoing cesarean section

BACKGROUND

Women undergoing cesarean section are vulnerable to adverse effects associated with inadvertent perioperative hypothermia, but there has been a lack of synthesized evidence for temperature management in this population. This systematic review aimed to synthesize the best available evidence in relation to preventing hypothermia in mothers undergoing cesarean section surgery.

METHODS

Randomized controlled trials meeting the inclusion criteria (adult patients of any ethnic background, with or without comorbidities, undergoing any mode of anesthesia for any type of cesarean section) were eligible for consideration. Active or passive warming interventions versus usual care or placebo, aiming to limit or manage core heat loss in women undergoing cesarean section were considered. The primary outcome was maternal core temperature. A comprehensive search with no language restrictions was undertaken of multiple databases from their inception until May 2012. Two independent reviewers using the standardized critical appraisal instrument for randomized controlled trials from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instruments (JBI-MASTARI) assessed retrieved papers for methodological quality and conducted data collection. Where possible, results were combined in a fixed effects meta-analysis using the Cochrane Collaboration Review Manager software. Due to heterogeneity for one outcome, random effects meta-analysis was also used.

RESULTS

A combined total of 719 participants from 12 studies were included. Intravenous fluid warming was found to be effective at maintaining maternal temperature and preventing shivering. Warming devices, including forced air warming and under-body carbon polymer mattresses, were effective at preventing hypothermia. However, effectiveness increased if the devices were applied preoperatively. Preoperative warming devices reduced shivering and improved neonatal temperatures at birth. Intravenous fluid warming did not improve neonatal temperature, and the effectiveness of warming interventions on umbilical pH remains unclear.

LINKING EVIDENCE TO ACTION

Intravenous fluid warming by any method improves maternal temperature and reduces shivering during and after cesarean section, as does preoperative body warming. Preoperative warming strategies should be utilized where possible. Preoperative or intraoperative warmed IV fluids should be standard practice. Warming strategies are less effective when intrathecal opioids are administered. Further research is needed to investigate interventions in emergency cesarean section surgery. Larger scale studies using standardized, clinically meaningful temperature measurement time points are required.

Evidence utilisation project: Management of inadvertent perioperative hypothermia. The challenges of implementing best practice recommendations in the perioperative environment

AIMS

The prevention of inadvertent perioperative hypothermia (IPH) remains an important issue in perioperative healthcare. The aims of this project were to: (i) assess current clinical practice in the management of IPH and (ii) promote best practice in the management of IPH in adult operating theatres.

METHODS

This project from August 2010 to March 2012 utilised a system of audit and feedback to implement best practice recommendations. Data were collected via chart audits against criteria developed from best practice recommendations for managing IPH. Evidence-based best practices, such as consistent temperature monitoring and patient warming, were implemented using multifaceted interventions.

RESULTS

Perioperative records for 73 patients (baseline) and 72 patients (post-implementation) were audited. Post-implementation audit showed an increase in patients with temperatures >36°C admitted to the post-anaesthetic care unit (PACU) (8%) and discharged from PACU (28%). The percentage of patients receiving preoperative temperature monitoring increased (38%); however, low levels of intraoperative monitoring remained (31% of patients with surgery of 30 min or longer duration). Small increases were found in patient warming of 5% intraoperatively and 8% postoperatively. Preoperative warming was not successfully implemented during this phase of the project.

CONCLUSION

Temperature monitoring, warming and rates of normothermia improved; however, barriers to best practice of IPH management were experienced, which negatively impacted on the project. Further stages of implementation and audit were added to further address IPH management in this department.

Perioperative hypothermia in NICU infants: its occurrence and impact on infant outcomes

Infants admitted to the neonatal intensive care unit (NICU) often require surgical intervention and maintaining normothermia perioperatively is a major concern. In our preliminary study of 31 normothermic infants undergoing operative procedures in the operating room (OR), 58% (N = 18) returned hypothermic while all 5 undergoing procedures in the NICU remained normothermic (P = .001). To describe perioperative thermal instability (temperatures lower than 36.0°C) and frequency of associated adverse events, support interventions, and diagnostic tests in infants undergoing operative procedures in the OR and the NICU. This prospective, case-control study included 108 infants admitted to the NICU who were sequentially scheduled for an operative procedure in the OR (50.93%; N = 55) or the NICU (49.07%; N = 53). Existing data from the medical record were collected about temperatures and frequency of adverse cardiovascular, respiratory, and metabolic events, associated support interventions, and diagnostic tests during the perioperative period. Analyses examined the relative risks and proportional differences in rates of hypothermia between the OR group and the NICU group and associated adverse events, support interventions, and diagnostic tests between hypothermic and normothermic infants. Hypothermia developed in 40% (N = 43) of infants during the perioperative period. The OR group had a higher rate of perioperative hypothermia (65.45%, N = 36; P < .001) and were 7 times more likely to develop perioperative hypothermia (P = .008) than the NICU group (13.21%, N = 7). Likewise, infants in the OR group were 10 times more likely to develop hypothermia during the intra- and postoperative periods than those in the NICU group (P = .001). The hypothermic group had significantly more respiratory adverse events (P = .025), were 6 times more likely to require thermoregulatory interventions (P < .001), 5 times more likely to require cardiac support interventions (P < .006), and 3 times more likely to require respiratory interventions (P = .02) than normothermic infants. Although infants undergoing operative procedures in the OR experienced significantly higher rates of hypothermia than those undergoing procedures in the NICU, both groups experienced unacceptable rates of clinical hypothermia. Hypothermic infants experienced more adverse events and required more support interventions during the intra- and postoperative periods than normothermic infants, thereby demonstrating the negative sequelae associated with thermal instability. As a result, a translational team of key stakeholders has been created to explore multifaceted strategies based on translation science to implement, embed, and sustain perioperative thermoregulation best practices for the infant, regardless of the operative setting.

[Prewarming. Yesterday's luxury, today's minimum requirement]

Prewarming is a useful and effective measure to reduce perioperative hypothermia. Due to §23(3) of the German Infektionsschutzgesetz (Gesetz zur Verhütung und Bekämpfung von Infektionskrankheiten beim Menschen, Infection Act, act on protection and prevention of infectious diseases in man) and the recommendations of the Hospital Hygiene and Infection Prevention Committee of the Robert Koch Institute, implementation of prewarming is clearly recommended. There are several technically satisfactory and practicable devices available allowing prewarming on the normal hospital ward, in the preoperative holding area or in the induction room of the operating theater (OR) The implementation of prewarming requires additional equipment and training of staff. Using a locally adapted concept for the implementation of prewarming does not lead to inefficiency in the perioperative process. In contrast, the implementation can help to achieve stable arrival times for patients in the OR.

Preventing hypothermia in elective arthroscopic shoulder surgery patients: a protocol for a randomised controlled trial

Background

Patients having arthroscopic shoulder surgery frequently experience periods of inadvertent hypothermia. This common perioperative problem has been linked to adverse patient outcomes such as myocardial ischaemia, surgical site infection and coagulopathy. International perioperative guidelines recommend patient warming, using a forced air warming device, and the use of warmed intraoperative irrigation solutions for the prevention of hypothermia in at-risk patient groups. This trial will investigate the effect of these interventions on patients’ temperature, thermal comfort, and total recovery time.

Method/Design

The trial will employ a randomised 2 x 2 factorial design. Eligible patients will be stratified by anaesthetist and block randomised into one of four groups: Group one will receive preoperative warming with a forced air warming device; group two will receive warmed intraoperative irrigation solutions; group three will receive both preoperative warming and warmed intraoperative irrigation solutions; and group four will receive neither intervention. Participants in all four groups will receive active intraoperative warming with a forced air warming device. The primary outcome measures are postoperative temperature, thermal comfort, and total recovery time. Primary outcomes will undergo a two-way analysis of variance controlling for covariants such as operating room ambient temperature and volume of intraoperative irrigation solution.

Discussion

This trial is designed to confirm the effectiveness of these interventions at maintaining perioperative normothermia and to evaluate if this translates into improved patient outcomes.

Australian New Zealand Clinical Trials Registry number

ACTRN12610000591055