Transcript Unintended Hypothermia: The Importance of Maintaining

3M Infection Prevention Solutions
Learning
Connection
Infection
Prevention
Division
Essentials EDU Learning Program
Prewarming:
Maintaining Normothermia
from the Start
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Disclosure
Sponsored by 3M, Infection Prevention Division
3M Health Care is a provider approved by the California Board of
Registered Nursing
Registered nurse participants can receive up to 1.0 contact hour
upon course completion
Presented by Cherrilyn Baker, RN, BSN, MBA
Clinical Specialist
3M Infection Prevention Division
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Course Objectives

Explain how the body’s thermoregulation system works

Define unintended perioperative hypothermia




Identify adverse patient outcomes associated with
unintended perioperative hypothermia
Discuss the definition of prewarming and associated
clinical studies
Explain why prewarming is beneficial in the prevention of
unintended perioperative hypothermia
Identify industry initiatives and guidelines citing
normothermia
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THE THERMOREGULATION SYSTEM
Presentation Title
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Normothermia


Normothermia: the body’s ideal
thermal state
Approximately 37.0°C (98.6°F)
Temperature gradient:1


37oC
Normal core temperature:1


Hypothalamus
2-4°C between the core and periphery
Hypothalamus1,2,3

Regulates core body temperature
1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997;336(24):1730-1737.
2. Guyton AC, Hall JE. Textbook of Medical Physiology. 10th Ed. © 2000.
3. De Witte J, Sessler DI. Anesth. 2002;96(2):467-84.
periphery
2-4oC cooler
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Thermoregulation:
Under Normal Circumstances
0.2°C Interthreshold Range
Vasoconstriction
Vasodilation
NST
Sweating
Shivering
32
33
34
35
36
37
38
39
40
41
The body’s normal response to temperature (°C)
Adapted from: Sessler DI. Temperature Monitoring. In: Miller RD, ed. Anesthesia. 3rd ed. New York: Churchill/Livingstone 1990.
1.
4.
Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997;336(24):1730-1737.
Sessler DI. Temperature Monitoring. In: Miller RD, ed. Anesthesia. 3rd ed. New York: Churchill/Livingstone 1990.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Effects of Anesthesia
Depressed Hypothalmus
4.0°C Interthreshold Range
Vasoconstriction
Vasodilation
NST
Sweating
Hypothermia :
< 36.0°C
32
33
34
35
36
37
38
39
40
41
Anesthesia-impaired response to temperature (°C)
Adapted from: Sessler DI. Temperature Monitoring. In: Miller RD, ed. Anesthesia. 3rd ed. New York: Churchill/Livingstone 1990.
1.
4.
Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997;336(24):1730-1737.
Sessler DI. Temperature Monitoring. In: Miller RD, ed. Anesthesia. 3rd ed. New York: Churchill/Livingstone 1990.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Effects of Anesthesia
Metabolic Heat Production
40-year-old (70kg) patient5



Awake: 70 kilocalories heat/hour
Anesthetized: 42 kilocalories
80-year-old (70kg) patient5


Awake: 60 kilocalories heat/hour
Anesthetized: 38 kilocalories
80
70
Kilocalories/hr

Metabolic Heat Production
40-Year-Old
80-Year-Old
70
60
60
50
42
40
5
38
30
20
10
-
Awake
Anesthetized
Adapted from: Morrison, International Anesthesiology Clinics, 1988
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Effects of Anesthesia
Heat Redistribution



Anesthesia causes vasodilation, or an
opening of arterial shunts, allowing the
warm blood from the core to flow freely
and mix with the colder periphery
As the blood circulates, it cools until
returning back to the heart where it causes
a drop in core temperature
This is known as heat redistribution
cold environment
1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997;336(24):1730-1737.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Characteristic Patterns of General
Anesthesia-Induced Hypothermia



Core temperature can drop
1.6°C in the first hour of
general anesthesia5, 6
1hr
0
Core
Temp
(C°)
81% of this temperature
decrease is due to core-toperipheral heat redistribution6
Commonly known as
redistribution temperature
drop5,6
-1
-2
-3
CORE TEMP
DECREASE
0
2
4
6
Elapsed Time (h)
Adapted from: Sessler DI, Anesth. 2000; 92(2): 578-96.
5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596.
6. Matsukawa T, Sessler DI, Sessler AM, Schroeder M, Ozaki M, Kurz A, Cheng C. Heat Flow and Distribution During Induction of General Anesthesia. Anesth. 1995;82(3):662-673.
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Phases of Hypothermia Development
Typical Pattern of Hypothermia during General Anesthesia
1hr
Phase I: Rapid decrease in core temperature
primarily caused by redistribution of heat.
Heat loss: 81% redistribution; 19% environmental
0
Core
Temp
(C°)
Phase II: Slower, linear decrease in temperature
primarily caused by heat loss which exceeds the body’s
ability to produce heat
-1
-2
Phase III: Temperature plateaus once it has
dropped beyond the widened interthreshold range
and triggers the thermoregulatory response
-3
CORE TEMP
DECREASE
0
2
4
6
Elapsed Time (h)
Adapted from: Sessler DI, Anesth. 2000; 92(2): 578-96.
5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596.
6. Matsukawa T, Sessler DI, Sessler AM, Schroeder M, Ozaki M, Kurz A, Cheng C. Heat Flow and
Distribution During Induction of General Anesthesia. Anesth. 1995;82(3):662-673.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Causes of Unintended Perioperative
Hypothermia

Administration of anesthetic
drugs leading to heat
redistribution1,5
•
•
General anesthesia
Regional anesthesia

Exposed body cavities1,5

Cold O.R. temperatures1,5

Length of surgery1,5

Infusion of cold fluids and blood1,5
1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737.
5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Maintaining Patient Normothermia


The induction of anesthesia is the most significant
contributor to unintended perioperative hypothermia
in surgical patients1,5
Reducing the impact of redistribution temperature
drop through prewarming is an effective way to help
maintain patient normothermia1,5
1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737.
5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
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MAINTAINING NORMOTHERMIA:
OUTCOMES, ECONOMICS, &
INITIATIVES
Presentation Title
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Unintended Perioperative Hypothermia




Perioperative hypothermia is defined as any core
temperature less than 36.0°C (96.8°F)1,5,7
Unintended perioperative hypothermia is considered
a frequent, preventable complication of surgery
Unless preventative measures are taken, unintended
perioperative hypothermia occurs in 50% to 90% of
surgical patients7
Research shows that even mild hypothermia can
result in significant negative outcomes
1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737.
5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596.
7. Young V, Watson M. Prevention of Perioperative Hypothermia in Plastic Surgery. Aesthetic Surgery Journal. 2006;551-571.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Adverse Effects of Unintended
Perioperative Hypothermia

There are many documented adverse effects of
unintended perioperative hypothermia including:8

Wound infection

Myocardial ischemia and cardiac disturbances

Coagulopathy

Prolonged and altered drug effect

Increased mortality

Shivering and thermal discomfort

Delayed emergence from anesthesia
8. Sessler DI, Kurz A. Mild Perioperative Hypothermia. Anesthesiology News. October 2008: 17-28.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Benefits of Normothermia

Maintaining normothermia may yield positive results
such as:9

Reduction in the use of blood products

Shortened length of hospital stay

Decreased ICU time

Reduced rate of wound infection

Decreased likelihood of myocardial infarction

Lower mortality rates
9. Mahoney CB, Odom J. Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs.
AANA Journal. 1999;67(2):155-164.
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Meta-Analysis Results
Meta-Analysis Results9
Blood products
Cost Savings Range
$227 - $344
Hospital stay
$1,534 - $4,602
ICU time
$105 - $314
Wound infections
$549 - $1,697
Myocardial infarction
$68 - $90
Mechanical ventilation
$16 - $26
Mortality
Undefined
Total Per Patient Savings
$2,495 - $7,073
Adapted from: Mahoney, Odom, AANA Journal, 1999
9. Mahoney CB, Odom J. Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs.
AANA Journal. 1999;67(2):155-164.
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HAI and SSI Statistics

Hospital infections, including SSIs, are prevalent and costly



The fourth largest killer in the U.S., claiming more lives than
AIDS, breast cancer and traffic accidents combined7
SSIs may result in yearly medical costs of $1 billion to $10 billion8
Patients who acquire SSIs are shown to have:12
•
Readmitted to the hospital
•
Admitted to the ICU
•
Two times more likely to die
10. Klevens RM, Edwards JR, Richards CL, Horan TC, Gaynes RP, Pollock DA, Cardo DM. Estimating healthcare-associated infections in US hospitals, 2002. Public Health Rep. Mar 2007;122(2):160-6.
11. Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention, 2008. CDC. Available at http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf.
Accessed 5/1/2012.
12. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infection Control
Hospital Epidemiology, 1999;20:725–30.
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Surgical Wound Infections


Hypothermic patients are at a greater risk for SSI
Reduction in core
temperature of 1.9°C has
been shown to triple the
incidence of SSIs after colon
resection13
Length of hospital stay
increased for hypothermic
patients with SSI13
20%
Infection Rate*
15%
10%
5%
0%
Hypothermic
25
Normothermic
Length of Hospital Stay*
20
Days

15
10
5
0
Patients with wound infections
Patients without wound
infections
*Adapted from: Kurz et al., New Engl J Med, 1996
13. Kurz A, Sessler DI, Lenhardt R. Perioperative Normothermia to Reduce the Incidence of
Surgical-Wound Infection and Shorten Hospitalization. New Engl J Med. 1996;334:1209-1215.
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THE SCIENCE BEHIND PREWARMING
Presentation Title
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What Is Prewarming?

Prewarming: the application heat prior to
anesthesia for the purpose of increasing total
body temperature



Prewarming = “banking heat”
Total body temperature = the average combined
temperature of the periphery and core
Prewarming increases the temperature of the
periphery, which limits the amount of heat lost
from the core through redistribution
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Warming Goals

Goal of perioperative warming

Maintain normal core temperature during
pre-op, surgery, and post-op1,5
Post-op
Pre-op
O.R.
Temp
Temp
Temp
= ≥36.0°C
0

Goal of prewarming

Prevent or reduce RTD
during Phase I1,5,14
-1
Core
Temp
(C°)
-2
-3
CORE TEMP
DECREASE
0
1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737.
5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596.
14. Sessler DI, Schroeder M, Merrifield B, Matsukawa T, Cheng C. Optimal duration and temperature of
prewarming. Anesth. 1995;82(3): 674-681.
2
4
6
Elapsed Time (h)
Adapted from: Sessler DI, Anesth. 2000; 92(2): 578-96.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Surgical Site Infection Rates


Melling et al. studied 421 patients receiving 30 minutes of
prewarming vs. no prewarming15
30 minutes of prewarming appears to assist in the prevention of
SSIs15
Infection Rates
15%
10%
5%
0%
Unwarmed
Warmed
Adapted from: Melling AC et al. Lancet. 2001;358(9285):876-880.
15. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection
after a clean surgery: a randomized controlled trial. Lancet. 2001;358(9285):876-880.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Prewarming and Patient Satisfaction



Prewarming can provide both clinical and comfort benefits
Recent studies have examined the effects of prewarming
on patient comfort and satisfaction17,18,19
Prewarming with a forced-air warming gown vs. warmed
cotton blankets can positively affect patient comfort and
satisfaction17,18,19
Warmth can play a role in a
positive patient experience
17. O’Brien D, Greenfield ML, Anderson J, Smith B, Morris M. Comfort, satisfaction, and anxiolysis in surgical patients using a patient-adjustable comfort warming system: a prospective randomized clinical
trial. J PeriAnesth Nurs. Apr 2010; 25(2):88-93.
18. Leeth D, Mamaril M, Oman K, Krumbach B. Normothermia and patient comfort: a comparative study in an outpatient surgery setting. J PeriAnesth Nurs. Jun 2010;25(3):146-151.
19. Wagner VD, Byrne MJ, Kolcaba KL. Effects of Comfort Warming on Preoperative Patients. AORN Journal. September 2006:84(3):427-448.
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Impact of Preoperative Warming on Maintenance of
Normothermia and Outcome after Colorectal Surgery
Study Details
• Yilmaz M, Popwich D, Halverson A, Mullaghy E, McCarthy R. Anesth.
2008;109:A880
• 141 colorectal surgery patients
• Intraoperative warming vs. preoperative/intraoperative warming
Study Findings
Comparison of Patient Temperature
Intraoperative warming (n=82)
Preoperative/intraoperative warming (n=60)
38.0
37.5
Temperature ⁰C
• Normothermia in PACU patients is
achieved more effectively by
prewarming combined with
intraoperative warming versus only
using intraoperative warming20
• Prewarmed patients had a propensity
toward fewer infections and spent
less time in the hospital20
37.0
36.5
36.0
35.5
35.0
34.5
Pre-induction
Incision
End of Care
PAR Admit
Adapted from: Yilmaz M, et al. Anesth. 2008;109:A880.
20. Yilmaz M, Popwich D, Halverson A, Mullaghy E, McCarthy R. Impact of Preoperative Warming
on Maintenance of Normothermia and Outcome after Colorectal Surgery. Anesth. 2008;109:A880.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Preoperative Combined with Intraoperative SkinSurface Warming Avoids Hypothermia Caused by
General Anesthesia and Surgery
Study Details
• Vanni SM, Braz JR, Modolo NS, Amorim RB, Rodrigues GR. J. Clinical
Anesthesia. 2008;15:119-125.
• Prospective, randomized trial of 30 patients undergoing elective
abdominal surgery
Study Findings
• Combining prewarming with forced-air warming before the induction
of anesthesia followed by intraoperative warming with forced-air
warming prevented patients from experiencing hypothermia in
surgeries of at least two hours in length24
24. Vanni SM, Braz JR, Modolo NS, Amorim RB, Rodrigues GR. Preoperative Combined with Intraoperative
Skin-Surface Warming Avoids Hypothermia Caused by General Anesthesia and Surgery. Journal of Clinical
Anesthesia. 2003;15:119-125.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Prewarming vs. Intraoperative Warming
38
37
36
36
Core
Temp
(C°)
35
34
33
32
Prewarming + Intraop Warming:
Maintain the warmth already gained
while the patient was prewarmed by
monitoring temps and adjusting the
warming unit in the OR accordingly.
Pre + Intraop. Warming Group
Intraop. Warming Group
Control Group (no warming)
31
Intraop Warming Only:
To “re-warm” following temperature
afterdrop requires time and may
require maximum operating
temperature of warming device.
0
-75
-60
-45
-30
Preoperative
-15
0
30
Time (min)
60
90
120
end
Intraoperative
Adapted from: Vanni S., et al. J of Clinical Anesthesia. 2003; 15:119-125.
24. Vanni SM, Braz JR, Modolo NS, Amorim RB, Rodrigues GR. Preoperative Combined with Intraoperative
Skin-Surface Warming Avoids Hypothermia Caused by General Anesthesia and Surgery. Journal of Clinical
Anesthesia. 2003;15:119-125.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Prewarming Study Summary




Prewarming can prevent or reduce RTD14,22,25
Prewarming + intraoperative warming can help
patients achieve a higher core temperature in
PACU20,21,24
Prewarming is beneficial in procedures of
shorter duration23
Prewarming can positively affect patient
comfort and satisfaction17,18,19
14. Sessler DI, Schroeder M, Merrifield B, Matsukawa T, Cheng C. Optimal duration and temperature of prewarming. Anesthesiology. 1995;82(3):674-681.
17. O’Brien D, Greenfield ML, et al. Comfort, satisfaction, and anxiolysis in surgical patients using a patient-adjustable comfort warming system: a prospective randomized clinical trial. J Perianesth Nurs. Apr 2010; 25(2):88-93.
18. Leeth D, Mamril M, et al. Normothermia and patient comfort: a comparative study in an outpatient surgery setting. J Perianesth Nurs. Jun 2010;25(3):146-151.
19. Wagner VD, Byrne MJ, Kolcaba KL. Effects of Comfort Warming on Preoperative Patients. AORN Journal. September 2006:84(3):427-448.
20. Yilmaz M, et al. Impact of Preoperative Warming on Maintenance of Normothermia and Outcome after Colorectal Surgery. Anesth. 2008;109:A880.
21. Andrzejowski J, Hoyle J, Eapen G, Turnbull D. Effect of Prewarming on Post-Induction Core Temperature and the Incidence of Inadvertent Perioperative Hypothermia in Patients Undergoing General Anesthesia. Brit Journal of Anaesth. 2008;101(5):627-631.
22. Kiekkas P, Karga M. Prewarming: Preventing intraoperative hypothermia. BJPN. Vol 15 No 10. October 2005.
23. Camus Y, Delva E, Sessler DI, Lienhart A. Pre-Induction Skin-Surface Warming Minimizes Intraoperative Core Hypothermia. Journal of Clinical Anesthesia. 1995;7:384-388.
24. Vanni SM, et al. Preoperative Combined with Intraoperative Skin-Surface Warming Avoids Hypothermia Caused by General Anesthesia and Surgery. Journal of Clinical Anesthesia. 2003;15:119-125.
25. Glosten B, Hynson J, Sessler DI, McGuire J. Preanesthetic Skin-Surface Warming Reduces Redistribution Hypothermia Caused by Epidural Block. Anesth Analg. 1993;77:488-93.
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PREWARMING CONSIDERATIONS
Presentation Title
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Passive Warming




Cotton blankets are passive insulators –
they do not provide active warming27
Heat from a warmed cotton blanket is
quickly lost to its surroundings27
Patient heat loss is virtually identical with
warmed and unwarmed cotton blankets27
Passive warming is not an effective way to
prevent unintended perioperative
hypothermia
27. Sessler DI, Schroeder M. Heat Loss in Humans Covered with Cotton Hospital Blankets.
Anesth Analg. 1993; No. 1: 73-77.
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Active Warming

Active warming is the active application of heat


Examples: forced-air warming blankets or gowns, or conductive
warming blankets or pads
Studies demonstrate that prewarming can be achieved by
utilizing active warming methods such as forced-air
warming or conductive blankets22,28-32
22. Kiekkas P, Karga M. Prewarming: preventing intraoperative hypothermia. Br J Perioper Nurs. 2005;15(10):444-445.
28. Brauer A, Waeschle RM, Waeschle RM, Heise D, Perl T, Hinz J, Quintel M, Bauer M. Preoperative prewarming as a routine measure. Anaesthetist. 2012;59(9):842-850. *Study only available in German. Summary
based off internal English translation.
29. Kim JY, Shinn H, Oh YJ, Hong YW, Kwak HJ, Kwak YL. The effect of skin surface warming during anesthesia preparation on preventing redistribution hypothermia in the early operative period of off-pump coronary
artery bypass surgery. Eur J Cardiothoracic Surg. 2006;29(3):343-7.
30. Moayeri BS, Hynson JM, Sessler DI, McGuire J. Pre-induction skin-surface warming prevents redistribution hypothermia. Anesth. 1991;75:3A.
31. Shinn HK, Kwak YL, Oh YJ, Kim SH, Kim JY, Lee MH. Active Warming during Preanesthetic Period Reduces Hypothermia without Delay of Anesthesia in Cardiac Surgery. Korean J Anesthesiol. 2006;48(6):S5-10.
32. Kurz A, Kurz M, Poeschl G, Faryniak B, Redl G, Hackl W. Forced-Air Warming Maintains Intraoperative Normothermia Better Than Circulating-Water Mattresses. Anesth Analg. 1993;77(1):89-95.
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Active Warming vs. Passive Warming

Preprocedure warming for one hour can decrease the
amount of post-op hypothermia33
Forced-air Warming Gown
Cotton Gown
12%
49%
51%
88%
Normothermic in PACU
Hypothermia in PACU
Adapted from: Hooven K. J PeriAnesth Nurs. 2011;26(1):9-14.
33. Hooven K. Preprocedure warming maintains normothermia throughout the perioperative
period: a quality improvement project. J PeriAnesth Nurs. 2011;26(1):9-14.
Normothermic in PACU
Hypothermia in PACU
Adapted from: Hooven K. J PeriAnesth Nurs. 2011;26(1):9-14.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Prewarming and Fluid Warming



It is not possible to warm patients with warmed I.V. fluids
alone35
Warmed I.V. fluids cannot transfer enough energy to
prewarm surgical patients35
1 L. of saline at 37°C only increases a 70kg patient’s mean
body temperature by 0.03°C36
vs.
35. Sessler DI. Consequences and treatment of perioperative hypothermia. Anesth Clin N Am. 1994;12(3):425-426.
36. Horowitz PE, Delagarza MA, Pulaski JJ, Smith RA. Flow rates and warming efficacy with Hotline and Ranger blood/fluid
warmers. Anesth Analg. 2004;993(3):788-792.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Getting Started
1. Conduct a temperature audit
2. Implement a consistent,
accurate patient temperature
monitoring process
3. Actively prewarm patients
4. Consistent maintenance of
normothermia
“The hypothermia literature is in agreement that prewarming is
the key to maintaining normothermia in most patients.”7
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Monitor Patient Temperature

Monitor your patients’ intraoperative temperatures and
adjust temperature settings in the O.R. accordingly



Avoid patient sweating; intraoperative warming should not be
too aggressive
High, Medium, and Low Settings
Check PACU temperature


If patients are ≥36°C, they have achieved normothermia, and
you have successfully met the SCIP-Inf-10 normothermia
measure
If patients are uncomfortably warm, examine your O.R.
protocol and practices
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Prewarming Considerations
↓
↓
↓
↓
Remember:
Only 30 minutes of prewarming
with forced-air can “bank heat” in
the periphery and prevent or
reduce redistribution temperature
drop14
• The longer you prewarm (“bank heat”)
• The more heat added to the periphery
• The lower the temperature gradient
• The less severe temperature drop following anesthesia
induction
14. Sessler DI, Schroeder M, Merrifield B, Matsukawa T, Cheng C. Optimal duration and temperature of
prewarming. Anesth. 1995;82(3): 674-681.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Prewarming Considerations: Overview




All surgical patients – regardless of age, weight or other factors
– undergoing general anesthesia may be susceptible to RTD
Monitor patient temperature to maintain normothermia throughout
the entire perioperative period by starting in pre-op
Prewarming can be achieved by utilizing active warming
methods22
Studies demonstrate that prewarming can be achieved by utilizing
active warming methods such as forced-air warming or conductive
blankets22,28-32
22. Kiekkas P, Karga M. Prewarming: preventing intraoperative hypothermia. Br J Perioper Nurs. 2005;15(10):444-445.
28. Brauer A, Waeschle RM, et al. Preoperative prewarming as a routine measure. Anaesthetist. 2012;59(9):842-850. *Study only available in German. Summary based off internal English translation.
29. Kim JY, Shinn H, et al. The effect of skin surface warming during anesthesia preparation on preventing redistribution hypothermia in the early operative period of off-pump coronary artery bypass surgery.
Eur J Cardiothoracic Surg. 2006;29(3):343-7.
30. Moayeri BS, Hynson JM, Sessler DI, McGuire J. Pre-induction skin-surface warming prevents redistribution hypothermia. Anesth. 1991;75:3A.
31. Shinn HK, Kwak YL, et al. Active Warming during Preanesthetic Period Reduces Hypothermia without Delay of Anesthesia in Cardiac Surgery. Korean J Anesthesiol. 2006;48(6):S5-10.
32. Kurz A, Kurz M, Poeschl G, et al. Forced-Air Warming Maintains Intraoperative Normothermia Better Than Circulating-Water Mattresses. Anesth Analg. 1993;77(1):89-95.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Attest™ Sterile U Network
INDUSTRY INITIATIVES & GUIDELINES
Presentation Title
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Normothermia: An Important Topic
CMS
JC
CDC
SCIP
Patient
Normothermia
WHO
IHI
ASPAN
ASA
AORN
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Best Practices for Preventing SSIs

Clipping


Antibiotics


Use prophylactic antibiotics
appropriately
Temperature


Remove hair appropriately
Maintain normothermia
Sugar

Maintain glucose control
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Denominator
Numerator
CMS SCIP-Infection-10 Perioperative
Temperature Management Measure



Active warming used intraoperatively – OR –
At least one temp ≥36.0°C within 30 minutes
immediately before or 15 minutes
immediately after anesthesia end time37
All patients undergoing surgical procedures under
general or neuraxial anesthesia of 60 minutes or
longer37
37. Specifications Manual for National Hospital Inpatient Quality Measures Discharges
01-01-12 (1Q12) through 06-30-12 (2Q12).
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
CMS SCIP-Infection-10 Perioperative
Temperature Management Measure
What this means for facilities:
1.
Warming more patients – regardless of age
2.
Warming more procedures* – regardless of complexity
3.
Ensuring normothermia
Normothermia is the goal
*Excludes patients with physician documentation of Intentional Hypothermia for the procedure performed
37. Specifications Manual for National Hospital Inpatient Quality Measures Discharges
01-01-12 (1Q12) through 06-30-12 (2Q12).
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Hospital Compare



Hospital Compare is an online tool for consumers offered
by U.S. Department of Health & Human Services38
Gives consumers a tool to
assist in the selection of
care based on a variety of
metrics
Scores include:38





Patient satisfaction
Patient safety
Mortality
Readmission Rates
http://www.hospitalcompare.hhs.gov
SCIP Measures – including SCIP-Inf-10
for normothermia maintenance
38. U.S. Department of Health & Human Services. Hospital Compare: Process of Care Measures. Available
at http://www.hospitalcompare.hhs.gov. Accessed February 17, 2012.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS)


The first national, standardized, publicly reported survey to
measure patients' perspectives of their hospital experience39

Discharged patients answer 27 questions on their recent hospital stay

Designed for acute care hospitals
Beginning 10/1/2012, HCAHPS scores will be one of 13
measures used by CMS to calculate payment from its new
Hospital Value-Based Purchasing Program39


Adherence to the 12 quality care measures will be weighted at 70% of
the payment formula
The patient satisfaction surveys will account for the remaining 30%.
39. HCAHPS Fact Sheet. Centers for Medicare & Medicaid Services, Baltimore, MD.
http://www.hcahpsonline.org. Accessed: March 15, 2012.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
AORN’s Recommended Practices for
Unplanned Perioperative Hypothermia


Create a plan to reduce the risk of unintended perioperative
hypothermia 40
Monitor core temperatures starting in pre-op and continuing
throughout the perioperative process 40

15 minutes of prewarming prior to the start of anesthesia 40

Maintenance of normothermia during surgery 40

Utilize a warming modality such as: 40

Forced-air warming – Safe, proven, effective and commonly used

Circulating-water garments – Effective in adult and pediatric patients

Energy transfer pads – Effective in reducing hypothermia during off-pump
cardiac surgery
40. AORN. Recommended Practices for the Prevention of Unplanned Perioperative Hypothermia.
Standards, Recommended Practices, and Guidelines. Denver, Colorado: AORN, Inc. 2012.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
ASPAN Recommendations on Normothermia


ASPAN’s Evidence-Based Clinical Practice Guideline for
the Promotion of Perioperative Normothermia41
Specific recommendations for pre-op include:41

Assessing every patient by monitoring temperatures, identifying
risk factors and thermal comfort level of the patient

Utilizing active warming for patients with temperatures <36°C

Providing thermal comfort through passive measures

Consider prewarming – “Evidence suggests that prewarming for
a minimum of 30 minutes may reduce the risk of subsequent
hypothermia.”1,15,41
1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737.
15. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after a clean surgery: a randomized controlled trial. Lancet. 2001;358(9285):876-880.
41. Hooper VD, Chard R, Clifford T, Fetzer S, Fossum S, Godden B, Martinez E, Noble K, O’Brien D, Odom-Forren J, Peterson C, Ross J. ASPAN’s Evidence-Based Clinical Practice Guideline for the
Promotion of Perioperative Normothermia. J PeriAnesth Nurs. 2009:24(5):271-287.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Association of Surgical Technologists (AST)



AST adopted the Guideline Statement for the Maintenance
of Normothermia in the Perioperative Patient42
Institute a perioperative process to oversee and manage a
patient’s core body temperature42
Monitoring patient temperatures is a team effort involving
all perioperative personnel42
42. Association of Surgical Technologists. Guideline Statement for the Maintenance of
Normothermia in the Perioperative Patient. October 2005.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Attest™ Sterile U Network
CONCLUSION
Presentation Title
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Conclusion





Perioperative hypothermia is defined as any core temperature less
than 36.0°C (96.8°F)1,5,7
Research shows that even mild hypothermia can result in
significant negative outcomes
All surgical patients – regardless of age, weight or other factors –
undergoing general anesthesia may be susceptible to RTD
Prewarming can prevent or reduce RTD1,5,14,20
Studies demonstrate that prewarming can be achieved by utilizing
active warming methods such as forced-air warming or conductive
blankets22,28-32
1. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737.
5. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596.
7. Young V, Watson M. Prevention of Perioperative Hypothermia in Plastic Surgery. Aesthetic Surgery Journal. 2006;551-571.
14. Sessler DI, Schroeder M, Merrifield B, Matsukawa T, Cheng C. Optimal duration and temperature of prewarming. Anesthesiology. 1995;82(3):674-681.
20. Yilmaz M, et al. Impact of Preoperative Warming on Maintenance of Normothermia and Outcome after Colorectal Surgery. Anesth. 2008;109:A880.
22. Kiekkas P, Karga M. Prewarming: Preventing intraoperative hypothermia. BJPN. Vol 15 No 10. October 2005.
28. Brauer A, Waeschle RM, et al. Preoperative prewarming as a routine measure. Anaesthetist. 2012;59(9):842-850. *Study only available in German. Summary based off internal English translation.
29. Kim JY, Shinn H, et al. The effect of skin surface warming during anesthesia preparation on preventing redistribution hypothermia in the early operative period of off-pump coronary artery bypass surgery. Eur J Cardiothoracic
Surg. 2006;29(3):343-7.
30. Moayeri BS, Hynson JM, Sessler DI, McGuire J. Pre-induction skin-surface warming prevents redistribution hypothermia. Anesth. 1991;75:3A.
31. Shinn HK, Kwak YL, et al. Active Warming during Preanesthetic Period Reduces Hypothermia without Delay of Anesthesia in Cardiac Surgery. Korean J Anesthesiol. 2006;48(6):S5-10.
32. Kurz A, Kurz M, Poeschl G, et al. Forced-Air Warming Maintains Intraoperative Normothermia Better Than Circulating-Water Mattresses. Anesth Analg. 1993;77(1):89-95.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
Course Objectives

Explain how the body’s thermoregulation system works

Define unintended perioperative hypothermia




Identify adverse patient outcomes associated with
unintended perioperative hypothermia
Discuss the definition of prewarming and associated
clinical studies
Explain why prewarming is beneficial in the prevention of
unintended perioperative hypothermia
Identify industry initiatives and guidelines citing
normothermia
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
References
1.
Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737.
2.
Guyton AC, Hall JE. Textbook of Medical Physiology. 10th Ed. © 2000.
3.
De Witte J, Sessler DI. Perioperative Shivering. Anesth. 2002;96(2):467-84.
4.
Sessler DI. Temperature Monitoring. In: Miller RD, ed. Anesthesia. 3rd ed. New York: Churchill/Livingstone 1990.
5.
Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596.
6.
Matsukawa T, Sessler DI, Sessler AM, Schroeder M, Ozaki M, Kurz A, Cheng C. Heat Flow and Distribution During Induction of General Anesthesia. Anesth. 1995;82(3):662673.
7.
Young V, Watson M. Prevention of Perioperative Hypothermia in Plastic Surgery. Aesthetic Surgery Journal. 2006;551-571.
8.
Sessler DI, Kurz A. Mild Perioperative Hypothermia. Anesthesiology News. October 2008: 17-28.
9.
Mahoney CB, Odom J. Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs. AANA Journal. 1999;67(2):155-164.
10.
Klevens RM, Edwards JR, Richards CL, Horan TC, Gaynes RP, Pollock DA, Cardo DM. Estimating healthcare-associated infections in US hospitals, 2002. Public Health Rep.
Mar 2007;122(2):160-6.
11.
Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention, 2008. CDC. Available at
http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf. Accessed 5/1/2012.
12.
Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and
extra costs. Infection Control Hospital Epidemiology, 1999;20:725–30.
13.
Kurz A, Sessler DI, et al. Perioperative Normothermia to Reduce the Incidence of Surgical-Wound Infection and Shorten Hospitalization. New Engl J Med. 1996;334:1209-1215.
14.
Sessler DI, Schroeder M, Merrifield B, et al. Optimal duration and temperature of prewarming. Anesth. 1995;82(3): 674-681.
15.
Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after a clean surgery: a randomized controlled trial. Lancet.
2001;358(9285):876-880.
16.
Hogenmiller J, et al. Preventing Orthopedic Total Joint Replacement Surgical Site Infections through a Comprehensive Best Practice Bundle/Checklist. Hospital: Truman
Medical Center, Kansas City, MO. APIC abstracts, June 2011.
17.
O’Brien D, Greenfield ML, et al. Comfort, satisfaction, and anxiolysis in surgical patients using a patient-adjustable comfort warming system: a prospective randomized clinical
trial. J PeriAnesth Nurs. Apr 2010; 25(2):88-93.
18.
Leeth D, Mamril M, et al. Normothermia and patient comfort: a comparative study in an outpatient surgery setting. J PeriAnesth Nurs. Jun 2010;25(3):146-151.
19.
Wagner VD, Byrne MJ, Kolcaba KL. Effects of Comfort Warming on Preoperative Patients. AORN Journal. September 2006:84(3):427-448
20.
Yilmaz M, et al. Impact of Preoperative Warming on Maintenance of Normothermia and Outcome after Colorectal Surgery. Anesth. 2008;109:A880.
21.
Andrzejowski J, Hoyle J, Eapen G, Turnbull D. Effect of Prewarming on Post-Induction Core Temperature and the Incidence of Inadvertent Perioperative Hypothermia in
Patients Undergoing General Anesthesia. Brit Journal of Anaesth. 2008;101(5):627-631.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12
References
22.
Kiekkas P, Karga M. Prewarming: Preventing intraoperative hypothermia. BJPN. Vol 15 No 10. October 2005.
23.
Camus Y, Delva E, Sessler DI, Lienhart A. Pre-Inductive Skin-Surface Warming Minimizes Intraoperative Core Hypothermia. Journal of Clinical Anesthesia. 1995;7:384-388.
24.
Vanni SM, et al. Preoperative Combined with Intraoperative Skin-Surface Warming Avoids Hypothermia Caused by General Anesthesia and Surgery. Journal of Clinical
Anesthesia. 2003;15:119-125.
25.
Glosten B, Hynson J, Sessler DI, McGuire J. Preanesthetic Skin-Surface Warming Reduces Redistribution Hypothermia Caused by Epidural Block. Anesth Analg.
1993;77:488-93.
26.
Just B, et al. Prevention of Intraoperative Hypothermia by Preoperative Skin-Surface Warming. Anesth. 1993;79(2):214-218.
27.
Sessler DI, Schroeder M. Heat Loss in Humans Covered with Cotton Hospital Blankets. Anesth Analg. 1993; No. 1: 73-77.
28.
Brauer A, Waeschle RM, et al. Preoperative prewarming as a routine measure. Anaesthesist. 2012;59(9):842-850. *Study only available in German. Summary based off
internal English translation.
29.
Kim JY, Shinn H, et al. The effect of skin surface warming during anesthesia preparation on preventing redistribution hypothermia in the early operative period of off-pump
coronary artery bypass surgery. Eur J Cardiothorac Surg. 2006;29(3):343-7.
30.
Moayeri BS, Hynson JM, Sessler DI, McGuire J. Pre-induction skin-surface warming prevents redistribution hypothermia. Anesth. 1991;75:3A.
31.
Shinn HK, Kwak YL, et al. Active Warming during Preanesthetic Period Reduces Hypothermia without Delay of Anesthesia in Cardiac Surgery. Korean J Anesthesiol.
2006;48(6):S5-10.
32.
Kurz A, Kurz M, Poeschl G, et al. Forced-Air Warming Maintains Intraoperative Normothermia Better Than Circulating-Water Mattresses. Anesth Analg. 1993;77(1):89-95.
33.
Hooven K. Preprocedure warming maintains normothermia throughout the perioperative period: a quality improvement project. J PeriAnesth Nurs. 2011;26(1):9-14.
34.
Fossum S, Hays J, Henson MM. A Comparison Study on the Effects of Prewarming Patients in the Outpatient Surgery Setting. J PeriAnesth Nurs. 2002;16(3):187-194.
35.
Sessler DI. Consequences and treatment of perioperative hypothermia. Anesth Clin N Am. 1994;12(3):425-426.
36.
Horowitz PE, Delagarza MA, Pulaski JJ, Smith RA. Flow rates and warming efficacy with Hotline and Ranger blood/fluid warmers. Anesth Analg. 2004;993(3):788-792.
37.
Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-12 (1Q12) through 06-30-12 (2Q12).
38.
U.S. Department of Health & Human Services. Hospital Compare: Process of Care Measures. Available at http://www.hospitalcompare.hhs.gov. Accessed February 17, 2012.
39.
HCAHPS Fact Sheet. Centers for Medicare & Medicaid Services, Baltimore, MD. http://www.hcahpsonline.org. Accessed: March 15, 2012.
40.
AORN. Recommended Practices for the Prevention of Unplanned Perioperative Hypothermia. Standards, Recommended Practices, and Guidelines. Denver, Colorado:
AORN, Inc. 2012.
41.
Hooper VD, et al. ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia. J PeriAnesth Nurs. 2009:24(5):271-287.
42.
Association of Surgical Technologists. Guideline Statement for the Maintenance of Normothermia in the Perioperative Patient. October 2005.
©2012 Arizant Healthcare Inc. All Rights Reserved. 603545A – 07/12