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Reducing the Risk of UnplannePerioperative HypothermiaSUSAN LYNCH, RN, MSN, CNOR; JACQUELINE DIXON, RN, BSN, MSHA, CNOR; DONNA LEARY, RN, CNORwww.aorn.org/CE
2.2
outcomes,R include
s, skin andl in Media,tiveness ofrioperativece. Resultsperiopera-
) or higher53-562. ©
.
ABSTRACT
Maintaining normothermia is important for patient safety, positive surgicaland increased patient satisfaction. Causes of unplanned hypothermia in the Ocold room temperatures, the effects of anesthesia, cold IV and irrigation fluidwound exposure, and patient risk factors. Nurses at Riddle Memorial HospitaPennsylvania, performed a quality improvement project to evaluate the effecusing warm blankets, warm irrigation fluids, or forced-air warming on pepatients to maintain their core temperature during the perioperative experienof the project showed that 75% of patients who received forced-air warmingtively had temperatures that reached or were maintained at 36° C (96.8° Fwithin 15 minutes after leaving the OR. AORN J 92 (November 2010) 5AORN, Inc, 2010. doi: 10.1016/j.aorn.2010.06.015
Key words: normothermia, hypothermia, perioperative patient warming
imporgicaln. Mdecr
by asase thnplanecogationing su
90% of sur-illion pa-hypothermiay of periop-able surgicalimprove-
perioperativein nursing
, Media,eve optimalgoverningy, and mini-
TAINED?siologicalith heat loss.
contac
rn the
wing
leting
ation
hours
Perioperative normothermia isfor patient safety, positive sucomes, and patient satisfactio
ing normothermia has been proven topostoperative length of hospital stayas 40% and has been shown to decreof surgical site infections by 64%.1 Uperioperative hypothermia is widely ra preventable cause of many complicadverse reactions in patients undergo
indicates that continuing education
hours are available for this activity. Ea
tact hours by reading this article, revie
purpose/goal and objectives, and comp
online Examination and Learner Evalu
http://www.aorn.org/CE. The contact
this article expire November 30, 2013.
doi: 10.1016/j.aorn.2010.06.015
© AORN, Inc, 2010
rtantout-
aintain-ease themuche riskned
nized ass andrgical
interventions.2 An estimated 50% togical patients (ie, approximately 14 mtients) experience unplanned surgicaleach year.1,3,4 Thus, one responsibiliterative nurses is to prevent this avoidcomplication. We undertook a qualityment project to evaluate methods ofpatient warming to facilitate a changepractice at Riddle Memorial HospitalPennsylvania. Our goals were to achiresults in patient temperatures, meetagency requirements for patient safetmize patient risks.
HOW IS NORMOTHERMIA MAINThermal regulation is the body’s phymeans of balancing heat production w
t
con-
the
the
at
for
The hypothalamus regulates body temperature in
November 2010 Vol 92 No 5 ● AORN Journal 553
96.8°a pa
(96.8occureraturctionur dere ofrmiaringxyge, neul defeels, w
easurbe mand
bladdonitorre tebody
e esopchniqic.8 Bctal tne flourfacF) lomper
patienmin
allengOR,
ient roomtures, vaso-ion as a re-eneral anes-kin exposurey the surgi-
edure andf internalirrigationon, conduc-ant factorsdiation andto heat loss
at loss.11
for the re-
hat is giveny).12 Radia-ject surface
ace (eg, byair). Radiantvasodilata-nt heat lossloss, the
through a gasccurs as airskin (eg,
eat is trans-because of aon heat lossbody comesattresses,
ance from aheat loss
ng of liquidtions).
Ae hypother-atients at
November 2010 Vol 92 No 5 LYNCH—DIXON—LEARY
the central nervoussystem by acting as athermostat that re-sponds to tempera-ture changes. Normo-thermia is defined asa core body tempera-ture in the range of 36° C to 38° C (100.4° F).5 Hypothermia occurs whencore temperature drops below 36° C
Vasoconstriction or vasodilatationincrease or decrease the body’s tempNormal thermoregulatory vasoconstritains core body temperature two to fowarmer than the peripheral temperatubody. Vasoconstriction from hypothethe flow of nutrients to the body, altewound healing process by lessening oery to tissue. When oxygen is limitedphils, the first line of white blood celare not able to perform at optimal levincreases the risk for infection.7
Often, core body temperature is mthe pulmonary artery, but it also canin the distal esophagus, nasopharynx,panic membrane.8 The oral, axillary,tal, and forehead skin temperature mtechniques can be used to estimate coture.2 During general anesthesia, coreperatures are usually monitored in threctum, or bladder; however, these teinvasive and are considered unhygientemperature readings are similar to reture readings; however, decreased uripose interpretation difficulties. Skin stemperatures are usually 0.5° C (0.9°than oral temperatures.9 Core body teshould be monitored in anesthetizedall procedures that last longer than 30
TYPES OF HEAT LOSSMaintaining normothermia can be chthe perioperative environment. In the
Vasoconstthe flow owound hedelivery to
lose heat rapidly for many reasons, for exa
554 AORN Journal
F totient’s
° F).6
s toe.1
main-greesthe
reducesthen deliv-tro-nse,hich
ed inonitoredtym-er, rec-ingmpera-
tem-hagus,ues areladder
empera-w can
e siteweraturests forutes.10
ing inpatients
low ambtemperaconstrictsult of gthesia, scaused bcal proc
positioning requirements, exposure oorgans, and use of room-temperatureand IV fluids.7,11 Radiation, convectition, and evaporation are four importthat affect perioperative heat loss. Raconvection are the major contributorsand result in 85% of perioperative heConduction and evaporation accountmaining 15% of total heat loss.11
Radiant heat is a form of energy toff from a central source (eg, the bodtion is the transfer of heat from an obwithout direct contact to another surfremoving clothing, exposure to coldheat loss occurs through the skin bytion. Body positioning increases radia(eg, the fetal position minimizes heatsupine position increases heat loss).9
Convection is the transfer of heator liquid.13 Heat loss by convection oor liquid transfers across the patient’sprep solutions, irrigation solutions).
Conduction is a process whereby hferred from one substance to anotherdifference in temperature.14 Conductioccurs in the OR when the patient’sin contact with colder objects (eg, mequipment).
Evaporation is the change of a substliquid to a gaseous state.15 Evaporativeoccurs through sweating or by the dryisubstances on the patient (eg, prep solu
PERIOPERATIVE HYPOTHERMIThe causes of unplanned perioperativmia are numerous, and the types of p
n from hypothermia reducesrients to the body, altering theprocess by lessening oxygen
ue.
rictiof nutalingtiss
mple, risk vary. Ambient room temperatures, length of
, andionalperare re
relatening
fluidsto uny typ
eat lod hyp
uma,
uid s
condindocr1,2
ia afrespine sytemp
a, an
it (PA
mL.
dicattrolyt
hosof s
in theverinands can
he patientized. Thee heat is fur-hich affectrature.12
sia, warmerith cooler
s the redistri-lates and re-of induction,eart canf 1° C (1.8°in the first
is at risk foro- to three-is a slowperature-hours after
n cause car-d for me-se the riskF), a 30%emperatures
utter andd ventriculars below 28°peratures
r the preven-thermia” de-ovided totaining nor-hypother-
sess surgicalte to un-
implement aperativet risk of im-in Table 1.t’s baseline
UNPLANNED PERIOPERATIVE HYPOTHERMIA www.aornjournal.org
surgery, blood and fluid loss, anxietyeffects of anesthesia (eg, general, regtribute to a decrease in core body temaltering hypothalamic body temperatution.2 Wet skin preps, skin exposurespecific surgical procedures or positiothe use of cold or room-temperaturebody cavity irrigation also contributeplanned loss of heat.1 A patient’s bodvery thin, malnourished) can affect hdividuals at greater risk for unplannemia include
� neonates,� patients who have experienced tra� patients who experienced a burn,� older adults,� female patients,� patients experiencing significant fl
and� patients with certain pre-existing
(eg, peripheral vascular disease, eorders, pregnancy, open wounds).
Unplanned perioperative hypothermmultiple body systems, including thecardiovascular, adrenergic, and immutems.16 A 1.5° C (3.6° F) decrease incan increase
� muscle relaxation action;� the need for red blood cells, plasm
platelets;� time in the postanesthesia care un
and� blood loss by approximately 500
In addition, hypothermia can alter metabolism and cause variations in elecThese factors may result in prolongedstays and an increase in the incidencesite infections.1
Hypothermia increases discomfortanesthetized patient and results in shiwhich increases oxygen consumptionworkload of the myocardium, and thu
crease blood pressure.17 Overall, thermal dthe) con-ture bygula-d to, andfor-e (eg,ss. In-other-
hifts,
tionsine dis-
fectsratory,s-erature
d
CU);
ion me-e levels.pitalurgical
un-g,the
in-
fort is an unpleasant experience for tbefore and after he or she is anesthetbody’s ability to control and conservther impaired by anesthetic agents, wthe patient’s ability to regulate tempe
After induction of general anestheblood from the patient’s core mixes wperipheral blood; this is referred to abution phase. The cooler blood circuturns to the heart. Within 30 minutesthis cooled blood that returns to the hcause a core body temperature drop oF).1 The largest heat loss occurs withhour after induction, and the patientadditional heat loss during the next twhour period under anesthesia.1 Thisprocess, which is followed by a temloss plateau that occurs three to fourinduction.1
During anesthesia, hypothermia cadiac arrhythmias and increase the neechanical ventilation, which can increaof patient mortality.18 At 30° C (86°decrease in cardiac output occurs.17 Tbelow 30° C (86° F) produce atrial flfibrillation.1 Ventricular tachycardia anfibrillation result from core temperatureC (82.4° F), and asystole occurs at tembelow 15° C (50° F).1
PREVENTING HYPOTHERMIAAORN’s “Recommended practices fotion of unplanned perioperative hyposcribes optimal patient care and is prguide the perioperative nurse in mainmothermia and preventing unplannedmia.19 Perioperative nurses should aspatients for risks that would contribuplanned hypothermia and develop andplan to decrease these risks.6,19 A perionursing care plan for surgical patients abalanced body temperature is provided
The nurse should assess the patien
iscom- temperature on arrival in the holding area. TheAORN Journal 555
rature
utcometatement
e patient is atreturning tormothermiathenclusion ofe immediatestoperativeriod.
November 2010 Vol 92 No 5 LYNCH—DIXON—LEARY
TABLE 1. Nursing Care Plan for Surgical Patients at Risk of Imbalanced Body Tempe
Diagnosis Nursing interventionsInterim outcome
statementOs
Risk forimbalancedbodytemperature
� Assesses risk for normothermia regulation.� Assesses risk for inadvertent hypothermia.� Assesses risk for inadvertent hyperthermia.� Identifies physiological status by
� assessing diagnostic study results;� evaluating buccal membranes, sclera, and skin (eg,
dryness, cyanosis, jaundice);� performing or reviewing assessment of and identifying
deviations in the patient’s� peripheral tissue perfusion;� cardiovascular status;� respiratory system;� renal status;� nutritional status (eg, basal metabolic rate, weight
gain or loss, skin turgor); and� liver status (eg, ascites).
� Identifies patient’s NPO status before surgery.� Assesses baseline temperature.� Records patient’s height and current weight.� Plans nursing care based on physiological data.
� Reports deviation in diagnostic study results by� reporting variances in diagnostic study results (eg,
laboratory, pathology, hemodynamic monitoring) toappropriate members of the health care team;
� communicating physiological health status (eg, verbalreports, patient record) to appropriate teammembers; and
� collaborating with other health care providersregarding diagnostic study results or assessmentfindings.
� Implements thermoregulation measures by� selecting temperature-monitoring devices based on
identified patient needs;� implementing appropriate passive warming measures
to implement preoperatively (eg, head coverings,socks);
� implementing appropriate active warming measures(eg, forced-air warming, warmed irrigation and IVfluids, elevated OR room temperature);
� ensuring that devices are readily available, clean, andfunctioning according to manufacturers’ specificationsbefore inserting, attaching, or placing devices on thepatient;
� inserting or applying temperature-monitoring andregulation devices to the patient according to theplan of care, facility practice guidelines, andmanufacturers’ written instructions;
� The patient’stemperature is greaterthan 36° C (96.8° F)at time of dischargefrom the operating orprocedure room.
� Thornoatcothpope
556 AORN Journal
depen
, to n
ure b
rmia
very
se the
mai
e sho
e sur
in the
ing m
t hyp
irrig
to ro
ight o
are a
face a
to im
ce an
hour
s to r
tient
shou
sia c
ation fluids,
f the pa-
hich alter
loss. Periop-
ent methods
cover
dy, warm
the surgery).
ucts) or crys-
atient at
n can lower
ould be
tabolic, car-
o affect the
tive environ-
ntify and
nd work co-
e surgical
ovider) to
traopera-
.
ore tempera-
exposure,
can cause
can increase
utcometatement
UNPLANNED PERIOPERATIVE HYPOTHERMIA www.aornjournal.org
preoperative nurse should intervene,
the patient’s preoperative temperature
ize or maintain the patient’s temperat
surgery.
All patients are at risk for hypothe
OR; however, patients who are either
or elderly are at increased risk becau
heat more rapidly and are less able to
their body temperature.20,21 The nurs
vide passive warming measures befor
(eg, head coverings, socks) to mainta
tient’s temperature and plan for warm
sures in the OR to prevent inadverten
mia (eg, forced-air warming, warmed
and IV fluids, reduced body exposure
elevated OR temperature).
Patients with extremes in body we
dition (eg, thin, obese, malnourished)
for hypothermia because of body sur
weight ratios. The nurse should plan
all methods of temperature maintenan
ervation available for these patients.
Procedures that last more than one
that expose large patient body cavitie
and cool irrigation fluids place the pa
for hypothermia. Perioperative nurses
laborate with the surgeon and anesthe
TABLE 1. (Continued)
Diagnosis Nursing
� operating temperaturedevices according to m
� removing temperature-from the patient when
� ensuring that the maligcomplete and medicatexpiration date.
� Monitors body tempera� Monitors physiological p� Evaluates response to t
vider to determine the advisability of incre
ding on
ormal-
efore
in the
young
y lose
ntain
uld pro-
gery
pa-
ea-
other-
ation
om air,
r con-
t risk
rea to
plement
d pres-
and
oom air
at risk
ld col-
are pro-
the OR temperature, using warm irrig
and instituting forced-air warming.
Positions that expose large areas o
tient’s body to OR temperatures or w
normal circulation contribute to heat
erative team members should implem
to reduce the patient’s exposure (eg,
unnecessarily exposed areas of the bo
the areas of the body not involved in
Refrigerated fluids (eg, blood prod
talloid solutions administered to the p
room temperature or used as irrigatio
the core temperature. These fluids sh
warmed, if possible.19
Certain chronic conditions (eg, me
diac, respiratory) have the potential t
patient’s temperature in the periopera
ment. Perioperative nurses should ide
assess the patient for comorbidities a
operatively with other members of th
team (eg, surgeon, anesthesia care pr
treat comorbidities preoperatively, in
tively, and postoperatively as needed
Trauma can affect the patient’s c
ture, either as a result of prolonged
blood loss, or shock. Hypothermia
coagulopathies and acidosis, which
ventionsInterim outcome
statementOs
oring and regulationcturers’ written instructions;ring and regulation devices
ed; andyperthermia cart ise available and within
ters.regulation measures.
inter
-monitanufamonitoindicatnant hions ar
ture.arame
hermo
asing the risk of death. Trauma that involves burns
AORN Journal 557
to re
EAS
esia Ngoingned
s, inc, provIncrewarm
re hefectiv
rmic), thed. Thviceove
and rids anen) ahe painimutempee exp
at a
of hy
table
search andrmothermiaORN stan-ended prac-periopera-
o improves for patientsse the datavered to as-
making theices for pa-eatment andnt invest-eeting theCare Im-
nt Project22
ts inspired
ls on meth-
quality mea-
ate postoper-
olorectal
ts undergo-
edure: lapa-
g on this
us warming
ine which
e.
mbrane tem-
preopera-
procedure,
educator en-
sponsible
s were
anic mem-
etent in its
gineering
he thermom-
ming the
at sepa-
November 2010 Vol 92 No 5 LYNCH—DIXON—LEARY
can further affect a patient’s abilitytemperature.19
TEMPERATURE-REGULATING MIN THE PACUThe American Society of PeriAnesthrecommends that every patient undergery be considered at risk for unplanhypothermia and beassessed on admis-sion to phase IPACU.2 If the pa-tient’s temperature iswithin the normo-thermic range (ie,36° C to 38° C[96.8° F to 100° F]),then the PACU nurseshould institute maintenance measuremaintaining the patient’s temperaturepain control, and ensuring hydration.ambient room temperature, providingkets, and minimizing skin exposure aSocks and head coverings also are efinterventions.2
If the patient is within the hypotheature range (ie, � 36° C [� 96.8° F]warming measures should be instituteshould apply a forced-air warming deculating warm-water mattress and remclothing or blankets from the patientthem with dry ones.2,18 Warm IV flumidified and warmed gases (eg, oxygbe used.2 The nurse should monitor ttemperature every 30 minutes at a mhe or she returns to a normothermicBefore discharge from the PACU, thoutcomes include that
� the patient’s temperature registersmum of 36° C (96.8° F),
� the patient’s signs and symptomsmia are resolved, and
� the patient confirms that an accep
If the patiepostanesthmaintenanhypothermwarming m
level has been reached.2
558 AORN Journal
gulate
URES
ursessur-
ludingidingasing
blan-lpful.18
e
temper-n activee nurseor cir-weteplaced hu-lso cantient’sm untilrature.ected
mini-
pother-
comfort
OUR PROJECTThe purpose of our project was to reimplement best practices to ensure noin surgical patients and to meet the Adard of care outlined in the “Recommtices for the prevention of unplannedtive hypothermia.”19 Our focus was t
outcomeand to uwe recosist us inbest chotients’ trequipmements. MSurgical
proveme
normothermia goal for surgical patien
our management group to initiate tria
ods of patient warming.
Although the focus of the national
sures is normothermia in the immedi
ative period for patients undergoing c
surgery,23 we chose to monitor patien
ing our highest volume surgical proc
roscopic cholecystectomy. By focusin
subset of patients, we compared vario
mechanisms and processes to determ
would provide the best patient outcom
All patients received tympanic me
perature monitoring on entry into the
tive holding area, during the surgical
and in the PACU. The perioperative
sured that all health care providers re
for obtaining the temperature reading
trained on the proper use of the tymp
brane thermometer and deemed comp
use before the project. Biomedical en
staff members calibrated and tested t
eters regularly.
We conducted three trials of war
patient with different methods and
normothermic, thecare unit nurse should instituteeasures. If the patient is
he nurse should institute activeures.
nt isesia
ce mic, teas
rate intervals.
e nursesthermia,ssment,s are thesurgery).
facilitieseing ateg, pa-a mayny clinicaled hypo-ming be-ave the
PACUpose timeso that
decreaseambula-perative-air warm-
hypo-flow of
nned peri-ses in all
olm alsoarea.t of inter-
ds and Rec-
hermia.
J. 2006;
073-1084.
UNPLANNED PERIOPERATIVE HYPOTHERMIA www.aornjournal.org
Ambulatory Takeaways
Unplanned Perioperative HypothermiaUnplanned perioperative hypothermia is more than just a patient comfort issue. Perioperativ
have become increasingly aware of the many adverse effects of unplanned perioperative hypoforemost of which is the increased risk of surgical site infection. The preoperative patient asseperioperative interventions, and discharge criteria for preventing unplanned hypothermic eventsame no matter the type of health care facility (eg, inpatient, ambulatory surgery, office-basedNevertheless, ambulatory surgery nurses have an additional challenge that nurses in inpatientmight not experience. If a patient is identified during the preoperative nursing assessment as bincreased risk for unplanned hypothermia or, in fact, presents with pre-existing hypothermia (tients who are homeless, older adult patients, pediatric patients), nurses in the preoperative areencounter time constraints that make it difficult, if not impossible, to resolve the problem. Matrials have shown the effectiveness of preoperative forced-air warming for preventing unplannthermia,1-5 but ambulatory surgery nurses may lack the time needed to institute forced-air warfore surgery. Presenting evidence-based research to surgeons and facility managers will help pway to instituting routine preoperative warming in spite of the time constraints.
If a patient arrives in the postanesthesia care unit (PACU) in a hypothermic state, then thenurses continue intraoperative or initiate postoperative warming interventions. Again, this canchallenges. Typically, patients in ambulatory settings want to move through recovery quicklythey can go home as soon as possible, and it is also in the facility’s best interest financially, tothe length of the patient’s recovery time. The limited time that a patient has in recovery in antory setting may make it more difficult to achieve desired normothermia goals. If routine preowarming is implemented and standard intraoperative warming techniques are used (eg, forceding, warmed irrigation and IV fluids), then the incidence of patients arriving in the PACU in athermic state will be reduced, thus lessening the effect of prolonged PACU stays on the rapidpatients through the unit.
Preoperative assessment, perioperative interventions, and discharge criteria to prevent unplaoperative hypothermia are the same regardless of the surgical setting. Ambulatory surgery nurthree perioperative areas must take the necessary steps to avoid this very preventable surgicalcomplication.
Rebecca Holm, MSN, RN, CNOR, is a clinical editor, AORN, Inc, Denver, CO. Ms Hworks as a perioperative nurse in ambulatory surgery centers in the Denver metropolitanMs Holm has no declared affiliation that could be perceived as posing a potential conflicest in the publication of this article.
1. Recommended practices for the prevention of unplanned perioperative hypothermia. In: Perioperative Standarommended Practices. Denver, CO: AORN, Inc: 293-306.
2. Hegarty J, Walsh E, Burton A, Murphy S, O’Gorman F, McPolin G. Nurses’ knowledge of inadvertent hypotAORN J. 2009;89(4):701-713.
3. Paulikas CA. Prevention of unplanned perioperative hypothermia. AORN J. 2008;88(3):358-368.4. Good KK, Verble JA, Secrest J, Norwood BR. Postoperative hypothermia—the chilling consequences. AORN
83(5):1054-1066.5. Cooper S. The effect of preoperative warming on patients’ postoperative temperatures. AORN J. 2006;83(5):1
AORN Journal 559
anketnance pewere
usedstope
en anho wey. W
re surntrolkeep
R temto 7each
ng th
ary 2selecng ore any; wee pro
anketnt lefts ininclu
8 and
and
rs, annd 4
R, 5C (96
laparowarm
2008. Par-
8 and 25
and 44
rs,nd 44 years,
R, the tem-ased to orr higher.
ndomly se-Septemberg preopera-atively andoup included
8 and 25
and 44
rs,nd 25 years,
and 44 years.
R, 75% ofmaintained
monthsby review-ical patientsundergoing
es. Forced-patients.tients wasients main-F) or higher
. These data
November 2010 Vol 92 No 5 LYNCH—DIXON—LEARY
� Trial 1 (control group)—Warm blused to provide temperature maintethe intraoperative and postoperativ
� Trial 2—Warmed irrigation fluidsintraoperatively.
� Trial 3—Forced-air warming waseratively, intraoperatively, and po
Patient participants consisted of mwomen older than 18 years of age wdergoing laparoscopic cholecystectomsured the patients’ temperatures befoand then instituted the temperature-coassigned to each trial as the means topatients warm. We maintained the Oture between 20° C to 22.7° C (68° FWe compared patient temperatures inwithin the first 15 minutes after leavi
Trial 1From November 2007 through Februused warm blankets on 28 randomlytients as the only means of maintainiing body temperature. We did not usof warming the patient before surgerya warm blanket at the beginning of thand replaced it with another warm blend of the procedure before the patieOR. We also applied warmed blankethe PACU. Participants in this group
� one woman between the ages of 1years,
� 25 women between the ages of 25years,
� one woman older than age 45 yea� one man between the ages of 25 a
Within 15 minutes after leaving the Othe patients had temperatures of 36°or higher.
Trial 2In the second trial, we used warmedirrigation fluid as the only means of
We monitored a group of 28 randomly ass560 AORN Journal
s weree duringriods.
used
preop-ratively.
dre un-e mea-gerymethodthe
pera-3° F).group
e OR.
008, weted pa-warm-meansappliedcedureat the
t the
ded
25
44
d4 years.
4% of.8° F)
scopicing.
patients from June 2008 through Julyticipants in this group included
� two women between the ages of 1years,
� 22 women between the ages of 25years,
� two women older than age 45 yea� one man between the ages of 25 a
and� one man older than age 45 years.
Within 15 minutes after leaving the Operatures of 68% of the patients increwere maintained at 36° C (96.8° F) o
Trial 3We monitored another group of 28 ralected patients from August 2008 to2008. We initiated forced-air warmintively and continued its use intraoperpostoperatively. Participants in this gr
� one woman between the ages of 1years,
� 19 women between the ages of 25years,
� five women older than age 45 yea� one man between the ages of 18 a
and� two men between the ages of 25
Within 15 minutes after leaving the Opatient temperatures reached or wereat 36° C (96.8° F) or higher.
FOLLOW-UPWe conducted a follow-up project sixafter the collection of our initial dataing data on 28 randomly chosen surgolder than 18 years of age who wereprocedures from all surgical specialtiair warming had been used for theseOur review of the data from these paprofoundly positive: 100% of the pattained a temperature of 36° C (96.8°within 15 minutes of leaving the OR
igned showed that forced-air warming was successful
thersultsd bef
stayningour
rsingducatons.s for
es toing hon healsoningmings totaling rer blo
f using$7 to $20
30 minutesed-air warm-ures can stillAs a resultnow used. The newlyd remains anpatients. Ed-ns will con-gical proce-m ongoings of ourering the in-f time allto reach
UNPLANNED PERIOPERATIVE HYPOTHERMIA www.aornjournal.org
with patients and during procedures olaparoscopic cholecystectomy. The recated that forced-air warming initiategery and carried through the patient’sPACU is the best method for maintaithermia. We collaboratively reviewedwith perioperative staff members, nuistration personnel, members of the eanesthesia departments, and the surgeair warming yielded the best outcomecal patients in our project (Figure 1).
Companies offer an array of choicsurgical patients, but forced-air warmshown to reduce radiant and convectisimultaneously.7 Forced-air warmingcost-effective and efficient in maintaithermia.7 Preoperative forced-air warsurgical patient increases the patient’peripheral temperature, limits the coohis or her blood, and promotes warm
Figure 1. Percentage ofpatients in each projectgroup that achieved atemperature of 36° C(96.8° F) or higher within15 minutes after theprocedure.
turning to the patient’s core, which produc
thanindi-ore sur-in the
normo-findingsadmin-ion andForced-surgi-
warmas beenat lossis bothnormo-of thelate ofod re-
higher core temperature.23 The cost oforced-air warming is approximatelyper patient at this time.1
CONCLUSIONAlthough surgeries that last less thanoften do not trigger the need for forcing, patients undergoing short procedexperience unplanned hypothermia.1
of this project, forced-air warming isfor all surgical patients at our facilityadapted process was implemented anongoing practice for all our surgicalucation for staff members and surgeotinue, and random reviews of the surdure data will be conducted to confirpositive patient outcomes. The resultproject have sparked interest in furthvestigation to determine the amount opostoperative surgical patients require
es a desired temperatures. By investigating this, we
AORN Journal 561
tempstopehmar
ocols:. 2008
ASPAline foeriAn
perativtp://ww�218
warm//wwwnomic0.S, O’Gadverte
A teamostope929.aintaintient Srgery.ntainingcessed
J, Namared typeratu-1692.ndamMosb
rming06;83(
ypothe
ary. 7t.nary.
nary.
onary.4.i F, M
enousmic sitn ortho25(1):2er DJ.in sur
e Patient inElsevier; 2007.
ion of un-Perioperative
Denver, CO:
t important riskperative hypo-20.DS. Age-relatede cooling in
p Physiol.
ital Quality/www35ACC-elease_
.ate postopera-provementIllinois Hospi-iewer?a�
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November 2010 Vol 92 No 5 LYNCH—DIXON—LEARY
hope to achieve postoperative patientof 36° C (96.8° F) or higher in all posurgical patients in less than the bencminutes.
References1. Weirich TL. Hypothermia/warming prot
the not widely used in the OR? AORN J333-344.
2. Hooper VD, Chard R, Clifford T, et al.Evidence-Based Clinical Practice Guidemotion Perioperative Normothermia. J P2009;24(5):271-287.
3. The cold, hard facts of unintended periothermia. OR Today. 2009;9(7):13-15. ht.mdpublishing.com/article.aspx?ArticleIDcessed July 26, 2010.
4. Mahoney CB. The economics of patientpatient Surgery. 2005:6(10):55-60. http:.outpatientsurgery.net/issues/2005/10/ecopatient-warming. Accessed July 26, 201
5. Hegarty J, Walsh E, Burton A, MurphyF, McPolin G. Nurses’ knowledge of inthermia. AORN J. 2009;89(4):707-713.
6. Bitner J, Hilde L, Hall K, Duvandek T.proach to the prevention of unplanned phyperthermia. AORN J. 2007;85(5);921-
7. Choi JJ. Infection control guide: how mmothermia can reduce infections. Outpa2007;8(5):8-15: http://www.outpatientsuguides/infection-control/2007/how-mainnormothermia-can-reduce-infections. Ac2010.
8. Kiya T, Yamakage M, Hayase T, SatohThe usefulness of an earphone-type infrthermometer for intraoperative core temtoring. Anesth Analg. 2007;105(6):1688
9. Potter PA, Perry AG. Vital signs. In: FuNursing. 6th ed. St Louis, MO: Elsevier621.
10. Cooper S. The effect of preoperative wapostoperative temperatures. AORN J. 201113.
11. Paulikas CA. Prevention of unplanned hAORN J. 2008;88(3):358-368.
12. Radiation. In: Mosby’s Medical DictionLouis, MO: Mosby Elsevier; 2005:1582
13. Convection. In: Mosby’s Medical DictioLouis, MO: Mosby Elsevier; 2005:457.
14. Conduction. In: Mosby’s Medical DictioLouis, MO: Mosby Elsevier; 2005:437.
15. Evaporation. In: Mosby’s Medical DictiSt Louis, MO: Mosby Elsevier; 2005:68
16. Hasankhani H, Mohammadi E, MoazzamM, Naghgizadh M. The effects of intravtemperature on perioperative hemodynapost-operative shivering, and recovery isurgery. Can Oper Room Nurs J. 2007;
17. Kumar S, Wong PF, Melling AC, Leapperioperative hypothermia and warming
practice. Int Wound J. 2005;2(3):193-204.562 AORN Journal
eraturesrativeked 15
why are;87(2):
N’sr the Pro-esth Nurs.
e hypo-w. Ac-
ing. Out-
s-of-
ormannt hypo-
ap-rative
ing nor-urgery.et/-July 26,
iki A.mpanic
re moni-
entals ofy; 2005:
patients’5):1090-
rmia.
h ed. St
7th ed. St
7th ed. St
7th ed.
okhtarifluidsuation,paedic0-27.Effects ofgical
18. Rothrock JC, ed. Alexander’s Care of thSurgery. 13th ed. St Louis, MO: Mosby
19. Recommended practices for the preventplanned perioperative hypothermia. In:Standards and Recommended Practices.AORN, Inc; 2010:293-306.
20. Macario A, Dexter F. What are the mosfactors for a patient’s developing intraothermia? Anesth Anal. 2002;94(1):215-2
21. Frank S, Raja SN, Bulcao C, Goldsteinthermoregulatory differences during corhumans. Am J Physiol Regul Integr Com2000;279(1):R349-R354.
22. Specification Manual for National HospMeasures. The Joint Commission. http:/.jointcommission.org/NR/rdonlyres/4D460DF-44A3-BA76-33ED32C05DD8/0/RNotes_22b.pdf. Accessed July 26, 2010
23. Colorectal surgery patients with immeditive normothermia for Surgical Care ImProject—achieving the standard of care.tal Association. http://docs.google.com/vv&q�cache:EEbfLLPIM0sJ:www.ihatoissues/quality/colorectalsurg.pdf�Coloresurgery�patients�with�immediate�ponormothermia&hl�en&gl�us&pid�bl&ADGEEShSY1Esu-PkNsJObdQXi7xQnPyOIgiHrBgKzArEvsV0la8f8HzGlaUIE7bWnnxzWj_3jlWfPuwL4R4AVCaVSXKuBILMi6oT1dxsCFCMraO5CjoGGnqCsig�AHIEtbT_Bno1qhkOkhjW-K9Ku2Bcessed July 26, 2010.
Susan Lynch, RN, MSN, CNOR, ieducator in the Surgical Services DRiddle Memorial Hospital (Main LiMedia, PA. Ms Lynch has no declation that could be perceived as positial conflict of interest in the publicarticle.
Jacqueline Dixon, RN, BSN, MSHis the director of Surgical Services,Memorial Hospital (Main Line HeaPA. Ms Dixon has no declared affilcould be perceived as posing a poteflict of interest in the publication of
Donna Leary, RN, CNOR, is a patmanager at Riddle Memorial HospitLine Health), Media, PA. Ms Learydeclared affiliation that could be peposing a potential conflict of interes
publication of this article..2.aorn.org/CE
EXAMINATION
CONTINUING EDUCATION PROGRAM2wwwReducing the Risk of Unplanned
Perioperative Hypothermia
unplanned
ur conve-e Exami-
PURPOSE/GOAL
To educate perioperative nurses about evidence-based practices to preventperioperative hypothermia.
OBJECTIVES
1. Identify the incidence of unplanned perioperative hypothermia.2. Describe how body temperature is regulated.3. Discuss core body temperature measurement.4. Discuss causes of unplanned perioperative hypothermia.5. Describe the effects of unplanned perioperative hypothermia.6. Identify thermoregulation measures that perioperative nurses can use.
The Examination and Learner Evaluation are printed here for yonience. To receive continuing education credit, you must complete thnation and Learner Evaluation online at http://www.aorn.org/CE.
ts expia each
e
canby l
ing at optimalf infection.e body.
ng it difficultevel.3, and 4
ated by usingfrom sources
QUESTIONS
1. Approximately ___________ patienunplanned perioperative hypotherma. 100,000b. 1 millionc. 5 milliond. 14 million
2. Body temperature is regulated by tha. brain stem.b. hypothalamus.c. pituitary.d. frontal lobe.
3. Vasoconstriction from hypothermia1. inadvertently alter wound healing
oxygen delivery to tissue.
© AORN, Inc, 2010
erienceyear.
essening
2. prevent neutrophils from performlevels, which increases the risk o
3. reduce the flow of nutrients to th4. increase the patient’s pain, maki
to control the patient’s comfort la. 1 and 4 b. 2 andc. 1, 2, and 3 d. 1, 2, 3
4. Core body temperature can be estimtemperature monitoring techniquessuch as the
1. axilla.2. bladder.3. forehead skin.4. mouth.5. pulmonary artery.
6. rectum.November 2010 Vol 92 No 5 ● AORN Journal 563
nd 6, 4, 5
laddereratu
pretati
onitores th
quid i
nned p
nditio
surgical pro-
fluids forreps.nd 6, 4, 5, and 6
etabolismevels.
ent appropri-asdevices based
nder the pa-in the supine
e warmingrgery (eg,
warming mea-armed irriga-room
-monitoringient accordingice guidelines,ctions.nd 3, 4, and 5
linical editor,
s Bakewell
November 2010 Vol 92 No 5 CE EXAMINATION
a. 1, 3, and 5 b. 2, 4, ac. 1, 2, 3, 4, and 6 d. 1, 2, 3
5. A potential complication of using bature readings to estimate core tempdecreased urine flow can pose interdifficulties.a. trueb. false
6. Core body temperatures should be manesthetized patients for all procedulonger than _____ minutes.a. 30b. 45c. 60d. 90
7. Transfer of heat through a gas or lia. conduction.b. convection.c. evaporation.d. radiation.
8. Factors that can contribute to unplaative hypothermia include1. ambient room temperatures.2. effects of anesthesia.3. length of surgery.4. presence of some pre-existing co
The behavioral objectives and examination fo
with consultation from Susan Bakewell, MS,
have no declared affiliations that could be perceive
564 AORN Journal
, and 6
temper-re is thaton
red inat are
s called
erioper-
ns.
5. skin exposure related to specificcedures or positioning.
6. use of cold or room-temperaturebody cavity irrigation and skin pa. 1, 3, and 5 b. 2, 4, ac. 2, 3, 5, and 6 d. 1, 2, 3
9. Hypothermia can alter medication mand cause variations in electrolyte la. trueb. false
10. Perioperative nurses should implemate thermoregulation measures such1. selecting temperature-monitoring
on identified patient needs.2. placing warm irrigation bottles u
tient’s knees while the patient isposition.
3. implementing appropriate passivmeasures to implement before suhead coverings, socks).
4. implementing appropriate activesures (eg, forced-air warming, wtion and IV fluids, elevated ORtemperature).
5. inserting or applying temperatureand regulation devices to the patto the plan of care, facility practand manufacturers’ written instrua. 4 and 5 b. 1, 2, ac. 1, 3, 4, and 5 d. 1, 2, 3
program were prepared by Rebecca Holm, MSN, RN, CNOR, c
, director, Center for Perioperative Education. Ms Holm and M
r this
RN-BC
d as potential conflicts of interest in publishing this article.
.2.aorn.org/CE
LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM2wwwReducing the Risk of Unplanned
Perioperative Hypothermiae therograms as d
tives o
d peri
regul
asure
perati. 5.periop
4. 5.s that
rease
ual obighation
a result ofr question
B.)e? (Select all
team regard-
o change/im-.eting withnd acceptance
aluate theintervals untilest practice.
ce as a resultct all that
t relevant to
each othersd change.port to make a
t we verify the2.2 continuingte)
This evaluation is used to determinwhich this continuing education pyour learning needs. Rate the item
below.
OBJECTIVES
To what extent were the following objeccontinuing education program achieved?
1. Identify the incidence of unplannetive hypothermia.Low 1. 2. 3. 4. 5. High
2. Describe how body temperature isLow 1. 2. 3. 4. 5. High
3. Discuss core body temperature meLow 1. 2. 3. 4. 5. High
4. Discuss causes of unplanned periohypothermia. Low 1. 2. 3. 4
5. Describe the effects of unplannedhypothermia. Low 1. 2. 3.
6. Identify thermoregulation measureerative nurses can use.Low 1. 2. 3. 4. 5. High
CONTENT
7. To what extent did this article incknowledge of the subject matter?Low 1. 2. 3. 4. 5. High
8. To what extent were your individmet? Low 1. 2. 3. 4. 5. H
9. Will you be able to use the informthis article in your work setting?
applicant who successfully completes this program
© AORN, Inc, 2010
extent tomet
escribed
f this
opera-
ated.
ment.
veHigherativeHigh
periop-
your
jectives
from
10. Will you change your practice asreading this article? (If yes, answe#10A. If no, answer question #10
10A. How will you change your practicthat apply)1. I will provide education to my
ing why change is needed.2. I will work with management t
plement a policy and procedure3. I will plan an informational me
physicians to seek their input aof the need for change.
4. I will implement change and eveffect of the change at regularthe change is incorporated as b
5. Other:
10B. If you will not change your practiof reading this article, why? (Seleapply)1. The content of the article is no
my practice.2. I do not have enough time to t
about the purpose of the neede3. I do not have management sup
change.4. Other:
11. Our accrediting body requires thatime you needed to complete theeducation contact hour (132-minu
dentialing Center
eptance of this
rs. Each
1. Yes 2. No program:
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Creapproves or endorses products mentioned in the activity.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for accactivity for relicensure.
Event: #10502; Session: #4029 Fee: Members $11, Nonmembers $22
The deadline for this program is November 30, 2013.
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answe
can immediately print a certificate of completion.November 2010 Vol 92 No 5 ● AORN Journal 565