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Reducing the Risk of UnplannePerioperative HypothermiaSUSAN LYNCH, RN, MSN, CNOR; JACQUELINE DIXON, RN, BSN, MSHA, CNOR; DONNA LEARY, RN, CNOR

www.aorn.org/CE

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outcomes,R include

s, skin andl in Media,tiveness ofrioperativece. Resultsperiopera-

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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

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wing

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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 d

the) 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. The

AORN 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

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se the

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to ro

ight o

are a

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ent methods

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the surgery).

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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

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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 ass

560 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

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Denver, CO:

t important riskperative hypo-20.DS. Age-relatede cooling in

p Physiol.

ital Quality/www35ACC-elease_

.ate postopera-provementIllinois Hospi-iewer?a�

day.com/ctal�stoperative�srcid�

rta04-g9G1D7--pmbJ13&smvZOgg. Ac-

s a clinicalepartment atne Health),red affilia-ng a poten-ation of this

A, CNOR,Riddlelth), Media,iation thatntial con-this article.

ient careal (Mainhas norceived ast in the

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 PROGRAM

2wwwReducing 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 PROGRAM

2wwwReducing 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