The impact of ambient operating room temperature on neonatal and maternal hypothermia and associated morbidities: a randomized controlled trial

Preventing Hypothermia in Newborns With Congenital Anomalies in the Delivery Room

BACKGROUND

Thermoregulation interventions in the delivery room have historically focused on preterm infants and studies often exclude term infants or those infants with known congenital anomalies.

PURPOSE

The purpose of this quality improvement project was to reduce the rate of admission hypothermia in neonates of all gestational ages born with congenital anomalies and admitted to the intensive care unit (ICU).

METHODS

Utilizing the Institute for Healthcare Improvement model for improvement, implementation of plan, do study, act cycles focused on standardizing temperatures of the delivery room and resuscitation bed, recommendations for temperature monitoring, trialing polyethylene lined hats, and implementing a delivery room thermoregulation checklist.

RESULTS

Overall, the mean rate of neonates admitted to the ICU hypothermic (<36.5°C) decreased from 27% to 9% over an 8-month period.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The interventions significantly reduced the number of neonates admitted to the ICU with hypothermia. Implementation of thermoregulation bundles should apply to all neonates with congenital anomalies to decrease risks associated with hypothermia.

Reducing postoperative hypothermia in infants: Quality improvement in China

BACKGROUND

Unintended postoperative hypothermia in infants is associated with increased mortality and morbidity. We noted consistent hypothermia postoperatively in more than 60% of our neonatal intensive care (NICU) babies. Therefore, we set out to determine whether a targeted quality improvement (QI) project could decrease postoperative hypothermia rates in infants.

OBJECTIVES

Our SMART aim was to reduce postoperative hypothermia (<36.5°C) in infants from 60% to 40% within 6 months.

METHODS

This project was approved by IRB at Guangzhou Women and Children's Medical Center, China. The QI team included multidisciplinary healthcare providers in China and QI experts from Children's Hospital of Philadelphia, USA. The plan-do-study-act (PDSA) cycles included establishing a perioperative-thermoregulation protocol, optimizing the transfer process, and staff education. The primary outcome and balancing measures were, respectively, postoperative hypothermia and hyperthermia (axillary temperature < 36.5°C, >37.5°C). Data collected was analyzed using control charts. The factors associated with a reduction in hypothermia were explored using regression analysis.

RESULTS

There were 295 infants in the project. The percentage of postoperative hypothermia decreased from 60% to 37% over 26 weeks, a special cause variation below the mean on the statistical process control chart. Reduction in hypothermia was associated with an odds of 0.17 (95% CI: 0.06-0.46; p <.001) for compliance with the transport incubator and 0.24 (95% CI: 0.1-0.58; p =.002) for prewarming the OR ambient temperature to 26°C. Two infants had hyperthermia.

CONCLUSIONS

Our QI project reduced postoperative hypothermia without incurring hyperthermia through multidisciplinary team collaboration with the guidance of QI experts from the USA.

The Effects of Actively Warming the Patient on Maternal and Infant Well-Being in a Cesarean Section Operation

PURPOSE

Intraoperative warming is recommended for surgical patients under anesthesia, but there are insufficient studies on this topic in cesarean delivery patients under spinal anesthesia. The purpose of this study was to determine the effects of active warming on the mother and newborn during elective cesarean section.

DESIGN

This research was carried out in an experimental design with a pretest-posttest randomized intervention and control group.

METHODS

The research was conducted with 34 women (17 intervention and 17 control), who gave birth by cesarean section. The study examined outcomes for both mother and newborn. Women in the intervention group were heated by both active (warmed with carbon fiber resistive underbody heaters during surgery) and passive heating (preoperative- socks, nonelectrified wool blankets, etc). Only passive heating methods were applied to the women in the control group (preoperative). Neonatal Activity - Pulse - Grimace - Appearence - Respiration (APGAR) score, body temperature, cortisol, and blood glucose levels in the intervention and control groups were evaluated, while body temperature and shivering conditions were evaluated in the mother.

FINDINGS

Body temperature and first minute APGAR score of the infants in the intervention and control groups after cesarean section were 36.88 ± 0.27, 36.52 ± 0.32 (P = .002); 7.00 ± 0.36, 7.47 ± 0.64 (P = .009), respectively. Cortisol and blood glucose levels in the intervention and control groups were 3.55 ± 1.09, 4.51 ± 0.70 (P = .010), 77.94 ± 7.07, 72.47 ± 10.24 (P > .05), respectively. The body temperatures of the women in the intervention and control groups at 15, 30, and 45 minutes were significantly different (P < .05), while they were similar (P > .05) at 60 minutes. Oxygen saturation measured at 30 minutes during the operation was 97.10 ± 1.41 in the intervention group and 95.20 ± 1.78 in the control group (P < .05).

CONCLUSIONS

Active warming before, during, and after cesarean section affected body temperature, pulse, respiration, blood pressure, and oxygen saturation of women, and while it increased the body temperature and APGAR score of newborns, it decreased cortisol level.

A Randomized Trial of the Effects of Ambient Operating Room Temperature on Neonatal Morbidity

OBJECTIVE

Newborn hypothermia has been implicated in neonatal morbidity without randomized evidence that it compromises the infant. Our objective was to determine if a difference in operating room temperature at cesarean birth impacts neonatal morbidity.

STUDY DESIGN

Women undergoing cesarean delivery of a liveborn infant without major malformations were included. The institutional preexisting operating room temperature of 20°C (67°F) was compared with an experimental group of 24°C (75°F) by cluster randomization assigned on a weekly basis. Newborn hypothermia was defined as axillary temperature on arrival to the nursery of less than 36.5°C (<97.7°F). The primary outcome was a composite of neonatal morbidity including respiratory support, sepsis, hypoglycemia, and neonatal death.

RESULTS

Between November 2016 and May 2018, 5,221 women had cesarean deliveries at Parkland Hospital with 2,817 randomized to the standard care group and 2,404 to the experimental group. The rate of neonatal composite morbidity did not differ between the groups: standard care 398 (14%) versus experimental 378 (16%), p = 0.11. This was despite a significant decrease in the rate of neonatal hypothermia: standard care 1,195 (43%) versus experimental 414 (18%), p < 0.001. There was no difference in the composite outcome for preterm infants (<37 wk) between the groups: standard care 194 (49%) versus experimental 185 (54%), p = 0.25.

CONCLUSION

An 8°F increase in operating room temperature was significantly associated with a reduced rate of neonatal hypothermia, although this decrease was not associated with a significant improvement in neonatal morbidity. However, the increase in operating room temperature was met with resistance from obstetricians and operating room personnel. This trial is registered (registration no.: NCT03008577).

Evidence-based cesarean delivery: preoperative management (part 7)

Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.

The Impact of Sensory Stimuli on Healthcare Workers and Outcomes in Trauma Rooms: A Focus Group Study

OBJECTIVE

This study investigated issues related to noise, lighting, and temperature in trauma rooms that impact patient care and staff performance.

BACKGROUND

Uncontrolled sensory stimuli can hinder healthcare delivery quality in trauma rooms. High noise and temperature levels can increase staff stress and discomfort as well as patient discomfort. Conversely, proper lighting can decrease staff stress levels and reduce burnout. Sensory overload in trauma rooms is a crucial concern, but no studies have been conducted on this issue.

METHOD

Using a convenience sampling method, 65 trauma team members (e.g., surgeons, physicians, nurses) from six Level I trauma centers in the United States were recruited to participate in 20 focus groups. Focus groups were semi-structured and 1 hr long.

RESULTS

Staff covered issues related to communications and disruption from noise sources (e.g., equipment, conversations). Having control over lighting allows staff to change light intensity and facilitate their work during the resuscitation. A well-maintained temperature can provide patient comfort or reduce risk of hypothermia, given that patients can lose body heat rapidly due to loss of blood.

CONCLUSION

Excessive sensory stimuli can result in disrupted communication, fatigue, and stress, making staff susceptible to errors. Staffs' control over environmental conditions may lead to a more efficient, comfortable, and safer environment. Technology should be reliable and flexible to facilitate this.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Hats Off for Full-Term Healthy Newborns: No Benefits for Thermoregulation

BACKGROUND

Hyperthermia is a known risk for sudden unexpected infant death. The practice of hat placement at birth to prevent transient hypothermia may not be necessary and sets an early standard for clothing infants that may lead to hyperthermia postnatally.

OBJECTIVE

To examine the elimination of hats on thermoregulation (eg, hypothermia, <97.6°F) in full-term newborns with no abnormalities within 24 hours of birth.

METHODS

In 2018, an institution guideline discontinued the use of hats at birth. Subsequently, newborn body temperatures were respectively extracted from electronic health records and data were compared from 482 infants (>38 weeks' gestation and newborn birth weight >2500 g) prior to ( n = 257) and following ( n = 225) the practice change. Body temperatures prior to and after the practice change to eliminate hats use were compared.

RESULTS

No statistically significant difference was observed: (1) in the proportion of infants experiencing hypothermia with or without hat use, respectively, 23.7% compared with 31.1% ( P = .09) and (2) in the odds of an infant experiencing hypothermia when adjusting for relevant covariates (odds ratio = 1.44; 95% confidence interval 0.89-2.32; P = .14).

CONCLUSIONS

Our findings demonstrate that the use of hats on infants at birth had no measurable impact on newborn thermoregulation.

Physical environment of the operating room during cesarean section: A systematic review

INTRODUCTION

Environmental factors in the operating room during cesarean sections are likely important for both women/birthing people and their babies but there is currently a lack of rigorous literature about their evaluation. The principal aim of this study was to systematically examine studies published on the physical environment in the obstetrical operating room during c-sections and its impact on mother and neonate outcomes. The secondary objective was to identify the sensors used to investigate the operating room environment during cesarean sections.

METHODS

In this literature review, we searched MEDLINE a database using the following keywords: Cesarean section AND (operating room environment OR Noise OR Music OR Video recording OR Light level OR Gentle OR Temperature OR Motion Data). Eligible studies had to be published in English or French within the past 10 years and had to investigate the operating room environment during cesarean sections in women. For each study we reported which aspects of the physical environment were investigated in the OR (i.e., noise, music, movement, light or temperature) and the involved sensors.

RESULTS

Of a total of 105 studies screened, we selected 8 articles from title and abstract in PubMed. This small number shows that the field is poorly investigated. The most evaluated environment factors to date are operating room noise and temperature, and the presence of music. Few studies used advanced sensors in the operating room to evaluate environmental factors in a more nuanced and complete way. Two studies concern the sound level, four concern music, one concerns temperature and one analyzed the number of entrances/exits into the OR. No study analyzed light level or more fine-grained movement data.

CONCLUSIONS

Main findings include increase of noise and motion at specific time-points, for example during delivery or anaesthesia; the positive impact of music on parents and staff alike; and that a warmer theatre is better for babies but more uncomfortable for surgeons.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Combined Forced Air Warming and Warm Intravenous Fluid Strategy for Perioperative Hypothermia in Cesarean Delivery: A Systematic Review and Meta-Analysis

PURPOSE

Evaluate the effect of a combined forced-air warming (FAW) and warm intravenous fluid (IVF) modality on maternal and neonatal outcomes in cesarean delivery under neuraxial anesthesia.

DESIGN

Systematic Review and Meta-analysis.

METHODS

An extensive search was conducted using PubMed, Cochrane Library, MEDLINE, CINAHL, Google Scholar, and other grey literature. Only randomized controlled trials examining the combined modality on maternal temperatures were included. Risk ratio (RR), mean difference (MD), and standardized mean difference (SMD) were used to estimate outcomes with suitable effect models. Quality of evidence was assessed using the Risk of Bias and GRADE system.

FINDINGS

Nine trials involving 595 patients were included. Combined strategy showed a smaller change in maternal temperature from baseline by 0.42°C (MD, -0.42; 95% CI, -0.62 to -0.22; P < .0001), higher temperature on PACU arrival (MD, 0.46; 95% CI, 0.11-0.82; P = .01), 15 minutes (MD, 0.43; 95% CI, 0.19-0.67; P = .0004) and 30 minutes after surgery (MD, 0.38; 95% CI, 0.12-0.64; P = .005). Combined strategy also reduced the incidence of hypothermia (RR, 0.55; 95% CI, 0.31-0.95; P = .03), and shivering (RR, 0.40; 95% CI, 0.28-0.58; P < .00001) with improvement in maternal comfort score (SMD; 0.38; 95% CI, 0.08-0.69; P = .01). However, there were no differences in clinical indicators of adverse neonatal outcomes. Lack of participants blinding, and substantial heterogeneity were limitations of this review.

CONCLUSION

The use of combined FAW and warm IVF is an effective strategy in mitigating perioperative hypothermia in cesarean delivery under neuraxial anesthesia.

[The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]

OBJECTIVE

To identify procedures to reduce maternal morbidity during cesarean.

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds.

CONCLUSION

In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Development and validation of a risk prediction scale for hypothermia during cesarean section: A prospective study

Background

Evidence shows that active insulation can reduce the incidence of hypothermia during cesarean section; however, compliance is lower than recommended. Moreover, several aspects of temperature management via active heat preservation remain unclear, including patient indications, timing, methods, and duration. Therefore, promptly identifying parturients at a high risk for hypothermia during cesarean section is crucial.

Objective

To develop and validate a scale for predicting hypothermia in parturients during cesarean section.

Design

Prospective study.

Setting

Three grade A hospitals in Hunan Province, China.

Participants

The prediction scale was developed based on data from 369 parturients who underwent cesarean section from July 2018 to January 2019. Inclusion criteria were as follows: cesarean section under lumbar anesthesia, epidural anesthesia, or combined lumbar and epidural anesthesia; voluntary participation in the study and completion of the informed consent form; age >18 years.

Methods

Univariate and multivariate analyses were used to determine factors influencing hypothermia and establish the predictive model for hypothermia risk during cesarean section. The Hosmer-Lemeshow test was used to determine the goodness of fit of the prediction tool, and the area under the receiver operating characteristic curve was used to determine the predictive ability of the proposed scale. The cutoff value of the prediction scale was determined according to the Youden index.

Results

In the logistic regression prediction model, the Hosmer-Lemeshow goodness-of-fit test yielded a p-value of 0.425. The area under the receiver operating characteristic curve was 0.888. The model exhibited a good fitting effect and discriminant validity. Total risk scores for hypothermia ranged from 0 to 11. A score of 7 was used as the diagnostic cutoff value. Parturients during the operation who had total scores of ≥7 and <7 were considered the high-risk and low-risk groups, respectively. The area under the receiver operating characteristic curve for the scale was 0.891. The authenticity evaluation indicated that the incidence of hypothermia was significantly higher in the high-risk group than in the low-risk group.

Conclusions

The risk prediction scale developed in this study exhibits moderately predictive efficiency, sensitivity, and specificity for identifying parturients at high risk of hypothermia during cesarean section. Implementing this scale in clinical practice may help to decrease the incidence of hypothermia in such patients.

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abstract

This new predictive model can identify women who are at a high risk of hypothermia during cesarean section.

Admission temperature and neonatal outcomes - single-centre experience in Saudi Arabia

Objective

This study aimed to investigate the association between admission hypothermia (AH), neonatal mortality and major neonatal morbidities in preterm infants <33 weeks' gestation. An additional aim of the study was to examine changes in the prevalence of admission hypothermia after the initiation of a thermoregulation quality improvement (QI) project.

Method

This is a retrospective cohort study of preterm infants < 33 weeks' gestation born at King AbdulAziz Medical City Riyadh (KAMC-R) between January 2017 to December 2020.

Results

Eight-hundred infants were born during the study period. Four hundred and one infants (50.1%) had an admission temperature of <36.5 °C and a further 399 (49.9%) had an admission temperature of >36.5 °C. The mortality before discharge was 15.7% in infants with AH compared to 4.8% among those with an admission temperature above 36.5 °C. This remained statistically significant after adjustments for gestational age and maternal PET status on a multivariate analysis (P = .001, OR 2.7,95%CI 1.5-4.7). The need for mechanical ventilation (P = .005) and incidence of surgical NEC (P = .030) were significantly different between the two temperature groups. Mean (SD) admission temperature increased from 36.3 °C to 36.6 °C following the thermoregulation intervention program (P <.001). Admission temperature <36 °C is associated with higher mortality in the first week (P = .001, OR 3.3,95% CI (1.7-6.6)) and increased incidence of cystic PVL (P = .04, OR 2.1, CI (1.03-4.3)).

Conclusion

Preterm infants with AH suffered higher mortality and greater neonatal morbidities.

2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.

Maintaining normal temperature immediately after birth in late preterm and term infants: A systematic review and meta-analysis

AIM

Prevention of hypothermia after birth is a global problem in late preterm and term neonates. The aim of this systematic review and meta-analysis was to evaluate delivery room strategies to maintain normothermia and improve survival in late preterm and term neonates (≥34 weeks' gestation).

METHODS

Medline, Embase, CINAHL, CENTRAL and international clinical trial registries were searched. Randomized controlled trials (RCTs), quasi-RCTs and observational studies were eligible for inclusion. Risk of bias for each study and GRADE certainty of evidence for each outcome were assessed.

RESULTS

25 RCTs and 10 non-RCTs were included. Room temperature of 23 °C compared to 20 °C improved normothermia [Risk Ratio (RR), 95% Confidence Interval (CI): 1.26, 1.11-1.42)] and body temperature [Mean Difference (MD), 95% CI: 0.30 °C, 0.23-0.37 °C), and decreased moderate hypothermia (RR, 95% CI: 0.26, 0.16-0.42). Skin to skin care (SSC) compared to no SSC increased body temperature (MD, 95% CI: 0.32, 0.10-0.52), reduced hypoglycemia (RR, 95% CI: 0.16, 0.05-0.53) and hospital admission (RR, 95% CI: 0.34, 0.14-0.83). Though plastic bag or wrap (PBW) alone or when combined with SSC compared to SSC alone improved temperatures, the risk-benefit balance is uncertain. Clinical benefit or harm could not be excluded for the primary outcome of survival for any of the interventions. Certainty of evidence was low to very low for all outcomes.

CONCLUSIONS

Room temperature of 23 °C and SSC soon after birth may prevent hypothermia in late preterm and term neonates. Though PBW may be an effective adjunct intervention, the risk-benefit balance needs further investigation.

Early Interventions to Achieve Thermal Balance in Term Neonates

Hypothermia is one of the most recognized and potentially avoidable reasons for transfer of a term neonate to the NICU. Physiologic and physical factors involved in the loss of heat affect a neonate's ability to thermoregulate in extrauterine environments. At the same time, these processes are interdependently affected by hypothermia, hypoglycemia, and respiratory distress. Underlying principles and preventive measures to avoid hypothermia are presented with practical application to practice. The implementation of best practices will decrease NICU admissions that separate mothers and neonates at this critical time. Preventive measures, competent assessment guides, and early interventions offer measures to avert avoidable hypothermia-related admissions to the NICU.

Clinical Survey of Current Perioperative Body Temperature Management: What Major Factors Influence Effective Hypothermia Prevention Practice?

Purpose

Inadvertent intraoperative hypothermia (IIH) is generally associated with several postoperative complications. Inspite of the existing guidelines, the global incidence of IIH remains unacceptably high. Understanding the conditions that influence temperature management is critical for developing future interventions to improve the postoperative patient outcomes. This study aimed to identify the major factors that hinder the implementation of IIH prevention practices.

Methods

Through a literature research, pilot small-sample investigation, and expert suggestions, 11 factors that may hinder the implementation of IIH prevention practices were identified. A questionnaire was developed, and each question was used to assess each factor. After approval by the Research Ethics Board, the questionnaires were sent to the staff anaesthesiologists at two academic hospitals via WeChat. Each answer was coded according to the degree to which the factor was affected, as anticipated. Finally, the answers were analysed based on the 80/20 rule to identify the major barriers to effective temperature management.

Results

We included 195 participants. Knowledge, memory, attention and decision processes, beliefs about consequences, and environmental context and resources were the major factors, with cumulative composition ratios of 24%, 43.4%, 57.7%, and 70.7%, respectively. Meanwhile, behavioural regulation and social influence were the secondary factors, with cumulative composition ratios of 80.4% and 87.5%, respectively. Reinforcement, confidence in capacity, duty realisation, skills, and intention were the general factors with cumulative composition ratios of 94.3%, 99.8%, 100%, 100%, and 100%, respectively.

Conclusion

Four factors-knowledge, memory, attention and decision process, beliefs about consequences, and environmental context and resources-were the major factors that influence the effective hypothermia prevention practice.

Relevance to Clinical Practice

These major factors will be used in further studies as a basis to develop the corresponding solutions and improve the patient outcomes in clinical practice.

Thermoneutral Environment for Neonates: Back to the Basics

Thermoregulation is an essential component to the stability and long-term outcomes of newborns and critically-ill neonates. A thermoneutral environment (TNE) is an environment in which a neonate maintains a normal body temperature while minimizing energy expenditure and oxygen consumption. Neonates who experience thermal stability within a TNE demonstrate enhanced growth, decreased respiratory support, decreased oxygen requirements, increased glucose stability, reduced mortality, and reduced morbidities associated with hyperthermia and hypothermia. Heat exchange occurs between the neonate and surrounding environment through four mechanisms: evaporation, conduction, convection, and radiation. By recognizing the methods by which heat is lost or gained, the neonatal provider can prevent adverse conditions related to abnormal thermal control and support a thermoneutral neonatal environment.

Improvement in thermoregulation outcomes following the implementation of a thermoregulation bundle for preterm infants

AIM

Hypothermia is associated with increased morbidity and mortality in preterm infants. A local audit revealed 60% preterm infants ≤32 weeks gestation and/or very low birth weight (VLBW) infants (<1500 g) had an abnormal body temperature at admission. This study compares thermoregulatory outcomes before and after the implementation of a thermoregulation bundle in the birthing environment.

METHODS

This retrospective cohort study reviewed thermoregulatory data for all inborn preterm (≤32 weeks) and/or VLBW infants for a period of 30 months before (Group 1: 1st January 2013 to 30 June 2015) and after changes to thermoregulation practice (Group 2: 1st July 2015 to 31 December 2017). The key practice changes included: improved anticipation and staff preparedness, wrapping infant in a polyethylene sheet, using a polyethylene lined bonnet, using servo-control mode at birth and during transport.

RESULTS

There were 282 and 286 infants in group 1 and group 2 respectively, with similar baseline characteristics. A clinically and statistically significant improvement was observed in the proportion of infants with normothermia (33% in group 1 to 60% in group 2, P < 0.0001) including the sub-group of extremely preterm (<28 weeks gestation) infants (38 to 60%, P = 0.0083). A higher mean admission temperature was observed for group 2 (36.10°C ± 0.78 in group 1 vs 36.52°C ± 0.61 in group 2, P < 0.0001). Moderate hypothermia was reduced by two-thirds in group 2 (41-12%, P = <0.0001).

CONCLUSIONS

The introduction of a thermoregulation bundle improved admission temperature, improved the proportion of normothermia and reduced moderate hypothermia in preterm infants.

Influence of Monocalcium Phosphate on the Properties of Bioactive Magnesium Phosphate Bone Cement for Bone Regeneration

Bone defects occurring for various reasons can lead to deformities and dysfunctions of the human body. Considering the need for clinical applications, it is essential for bone regeneration to exploit a scaffold with bioactive bone cement. In this study, we fabricated bioactive magnesium phosphate bone cement (BMPC) at room temperature; then, it was set at to °Cand 100% humidity for 2 h. The process was as follows: Simulating a clinical environment, magnesium oxide (MgO) was formed by calcining basic magnesium carbonate (Mg2(OH)2CO3). MgO, potassium dihydrogen phosphate (KH2PO4) and carboxymethyl chitosan (C20H37N3O14, CMC) were mixed to form magnesium phosphate bone cement (MPC); then, monocalcium phosphate (Ca(H2PO4)2) was added to neutralize the alkaline product after MPC hydration to fabricate bioactive magnesium phosphate bone cement (BMPC). The influence of the doped content of Ca(H2PO4)2 on the properties of bone cement was discussed. The results showed that Ca(H2PO4)2 and CMC can adjust the setting time of bone cement to between 8 and 25 min. The compressive strength increased first and then decreased. After 48 h without additional pressure, the compressive strength reached the maximum value, which was about 38.6 MPa. Ca(H2PO4)2 and CMC can play a synergistic role in regulating the properties of BMPC. The BMPC was degradable in the simulated body fluid (SBF). The results of the cytotoxicity experiment and laser confocal microscopy experiment indicated that BMPC fabricated at room temperature had better biocompatibility and degradability, which was more consistent with clinical operation requirements. BMPC is a promising orthopedic material and is suitable for repairing bone defects.

Decreased moderate admission hypothermia in extremely preterm newborns

BACKGROUND

Admission temperature is inversely correlated with mortality and morbidity risk in extremely preterm newborns (EPNs). As almost all EPNs require advanced resuscitation at birth, we improved a simple and comprehensive management protocol to reduce admission hypothermia. This study reports the changes over the past 15 years in the rate of admission hypothermia in all EPNs. It clarified the distribution of admission temperature and the risk factors for developing admission hypothermia in recent EPNs.

METHODS

This single-center study retrospectively analyzed the EPNs delivered at our institution between January 2006 and December 2020. The comprehensive management protocol, including warming equipment, plastic wrapping, aluminum-polyethylene sheet, and room temperature, was applied to avoid heat loss during resuscitation. On admission, the rectal temperature was measured and defined as moderate (32.0-35.9 °C) or mild (36.0-36.4 °C) hypothermia.

RESULTS

Overall (n = 432), the rate of admission with moderate hypothermia decreased from 48% in 2006 to 8% in 2020. In the recent evaluation of 80 EPNs delivered in 2017-2020, 10 (13%) and 26 (33%) had moderate and mild hypothermia on admission, respectively. Extremely preterm newborns with moderate-to-mild hypothermia had a significantly smaller gestational age and lower birthweight than those without hypothermia. No significant differences in the other perinatal and environmental risk factors were observed between EPNs with and without hypothermia.

CONCLUSIONS

Our comprehensive management protocol reduced the rate of moderate hypothermia on admission in EPNs to only 13%. However, eliminating mild hypothermia remains a challenge and requires continuous improvement, especially in smaller EPNs.

Enhanced Recovery after Surgery: Cesarean Delivery

This review summarizes the importance of enhanced recovery after surgery (ERAS) implementation for cesarean deliveries (CDs) and explores ERAS elements shared with the non-obstetric surgical population. The Society for Obstetric Anesthesia and Perinatology (SOAP) consensus statement on ERAS for CD is used as a template for the discussion. Suggested areas for research to improve our understanding of ERAS in the obstetric population are delineated. Strategies and examples of anesthesia-specific protocol elements are included.

Maternal and fetal hypothermia: more preventive compliance is required for a mother and her fetus while undergoing cesarean delivery; a quality improvement review

OBJECTIVE

Cesarean delivery is common, involves two patients, has numerous multi-disciplinary health care providers involved in the delivery management, but has variable levels of anesthesia and health services implementation for decreasing maternal hypothermia and the maternal and neonatal morbidity (and mortality). Limited implementation for either of the ERAS-CD or the ERAC guidelines, for inadvertent or preventive maternal hypothermia, is likely to be occurring on labor delivery floors. This Quality Improvement (QI) review focuses on cesarean delivery and maternal hypothermia.

METHODS

This quality and safety initiative used SQUIRE 2.0 methodology and concurrent PubMed searches to identify systematic review, meta-analysis, topic directed studies, additional published cohorts in the topic area not included in SR/MA, limited case reports that had specific clinical outcomes related to maternal hypothermia and fetal effects.

RESULTS

Two quality and safety improvement guidelines have defined the hypothermia activity element differently, with ERAS-CD recommending to prevent hypothermia, while ERAC recommending to maintain normothermia. The peer-reviewed literature indicates that the knowledge associated with surgical hypothermia outcome is known but it is not implemented for maternal cesarean delivery care. Increased maternal-effect recognition, surveillance, triage, and evidenced-based protocol management is required for the maternal - neonatal dyad undergoing cesarean delivery for the clinical reduction/prevention of neonatal hypothermia that has proven evidence-based maternal morbidity and neonatal morbidity/mortality.

CONCLUSION

TEAM-based anesthesia, obstetrical, neonatology-pediatrics and nursing research collaboration is required through quality-safety-ERAS-ERAC directed processes. Healthcare system recognition and financial support is required for maternal-fetal-neonatal hypothermia prevention protocols implementation.

Association between preoperative toe perfusion index and maternal core temperature decrease during cesarean delivery under spinal anesthesia: a prospective cohort study

Background

The main mechanism of body temperature decrease during cesarean delivery under spinal anesthesia is core-to-peripheral redistribution of body heat, attributable to vasodilation. Perfusion index (PI) obtained with a pulse oximeter helps to assess peripheral perfusion dynamics by detecting the change in peripheral vascular tone. This study aimed to examine whether preoperative toe PI could predict the decrease in core temperature induced by spinal anesthesia during cesarean delivery.

Methods

Parturients undergoing scheduled cesarean delivery under combined spinal-epidural anesthesia from September 2019 to March 2020 were enrolled in this single-center prospective cohort study. All parturients received 0.5% hyperbaric bupivacaine (10 mg) with fentanyl (15 μg) intrathecally. A pulse oximeter probe was placed on the left second toe for continuous PI measurement. The 3 M™ Bair Hugger™ Temperature Monitoring System placed over the right temporal region was used to record core temperature over time. We evaluated the association between the maximum core temperature decrease, which is the primary outcome, and the preoperative toe PI at operating room (OR) admission using a segmented regression model (SRM) and a generalized additive model (GAM). The maximum core temperature decrease was defined as the difference between core temperature at OR admission and minimum intraoperative core temperature.

Results

Forty-eight patients were evaluated. In the SRM, the slope for the association between the maximum core temperature decrease and the preoperative toe PI changed from 0.031 to 0.124 after PI = 2.4%. Likewise, with the GAM, there was a small core temperature decrease when preoperative toe PI was greater than 2.0 to 3.0%.

Conclusions

Low preoperative toe PI was associated with maternal core temperature decrease during cesarean delivery under spinal anesthesia. Preoperative toe PI is a simple, non-invasive, and effective tool for the early prediction of perioperative core temperature decrease during cesarean delivery.

Trial registration

UMIN Clinical Trials Registry (registry number: UMIN000037965).

Hypothermia and neonatal morbimortality in very low birth weight preterm infants

OBJECTIVE

To assess the prevalence of hypothermia in the delivery room, at admission, and 2 to 3 hours after admission in the neonatal intensive care unit (NICU), factors associated and possible relationship with morbidity and mortality in preterm infants with very low birth weight (VLBW).

METHODS

Cross-sectional study with data collection based on a retrospective review of medical records and including infants born in 2016 and 2017, with birth weights <1500g, and gestational ages <34 weeks. Data about VLBW preterm infants, maternal data and temperature in the delivery room were analyzed. Hypothermia was considered when axillary temperature <36°C. For statistical analysis, the chi-square test or G test, canonical and Spearman correlation, and logistic regression were used.

RESULTS

149 newborns (NB) were included in the study. The prevalence of hypothermia in delivery room, at admission to the NICU and 2 to 3 hours after admission was 25.8%, 41.5% and 40.2%, respectively. The temperature of NBs was directly proportional to gestational age (p<0.010), birth weight (p<0.010), and Apgar score (p<0.050). There was an inverse association with hypothermia in the delivery room and cesarean delivery (OR 0.25; p=0.016).

CONCLUSIONS

Hypothermia was a prevalent problem in the studied population. The neonatal temperature was directly proportional to gestational age, birth weight and Apgar score. Hypothermia was associated with maternal factors, such as cesarean delivery. It is necessary to implement and improve strategies for its prevention.

A multimodal quality improvement approach to promote normothermia in very preterm infants

AIM

To achieve the National Neonatal Audit Programme (NNAP) standard of 90% normothermia among preterm infants born under 30 weeks of gestation.

METHODS

Project SHIP (Stopping Hypothermia In Premmies) was a quality improvement programme to improve admission normothermia. Phase 1 of the project implemented low-fidelity simulations during 2011-2016. In Phase 2 (2017), a multimodal approach to quality improvement was used, including in situ simulations, videos of simulated scenarios, an allocated team member for thermal care, a clear protocol for thermal care, a coordinating 'lollipop man' role and monthly performance feedback. Additionally, continuous temperature monitoring using servo-control during stabilisation was introduced during Phase 2. Phase 3 (2018-2019) focused on embedding practice and maintaining performance.

RESULTS

Phase 1 initiatives resulted in improvement of normothermia rates from 58% to 75%. However, the results plateaued. During Phase 2, the hypothermia rate fell from 16% to 3%. During Phase 3, this improvement in the hypothermia rate was sustained, achieving the standard of 90% normothermia in 2018 and falling just short in 2019 due to an increased hyperthermia rate.

CONCLUSION

A multimodal quality improvement approach achieved sustained improvement in normothermia. Continuous temperature monitoring during stabilisation allows resuscitating teams to plan interventions to treat hypothermia and hyperthermia.

Engaging Frontline Providers Prevents Hypothermia and Improves Communication in the Postoperative Neonate

BACKGROUND

Neonates undergoing surgery are at high risk for perioperative hypothermia. Hypothermia has been associated with increased adverse events. Transfer of care from the operating room (OR) to the neonatal intensive care unit (NICU) adds another layer of risk for this population introducing the potential for miscommunication leading to preventable adverse events.

PURPOSE

The aim of this quality improvement initiative is to decrease mean postoperative hypothermia rate and achieve compliance with use of a standardized postoperative hand-off in neonates transferred to the NICU from the OR.

METHODS

An interdisciplinary team identified opportunities for heat loss during the perioperative period. The lack of standardized perioperative communication between the NICU and the OR and postoperative communication between neonatology, anesthesiology, surgery, and nursing were noted. Guidelines for maintaining euthermia in the perioperative period and a standardized interdisciplinary postoperative hand-off communication tool were created.

FINDINGS/RESULTS

Mean rate for participation in the hand-off process increased from 78.8% to 98.4% during the study period. The mean hypothermia rate improved from 28.6% to 6.3% (P < .0001) and was sustained.

IMPLICATIONS FOR PRACTICE

Creating a hypothermia guideline and standardizing temperature monitoring can significantly decrease the rate of postoperative hypothermia in neonates. Standardization of transfer of care from OR to NICU increases consistent communication between the services.

IMPLICATIONS FOR RESEARCH

Future research and improvement efforts are needed to optimize the management of surgical neonates through their transfers of care.

Neonatal Thermoregulation: A Golden Hour Protocol Update

BACKGROUND

Premature infants are poor regulators of body temperature and are subjected to environmental factors that can lead to rapid heat loss, leaving them vulnerable to an increased risk of morbidity and mortality from hypothermia. Thermoregulation protocols have proven to increase survival in preterm infants.

PURPOSE

To evaluate a Plan-Do-Study-Act (PDSA) cycle on a previously implemented Golden Hour protocol at a military medical care facility for infants born at less than 32 weeks of gestation and weighing less than1500 g. Specific aims included the use of increased delivery/operating room temperatures and proper use of thermoregulatory devices (polyethylene bags and thermal mattress).

METHODS

Outcomes were analyzed and compared using a pre/postdesign. The data was collected using the neonatal intensive care unit admission worksheet.

RESULTS

Although statistical analysis was not significant, clinical significance was illustrated by a decrease in hypothermia rates on admission and at 1 hour of life. There was a 100% compliance rate with increasing delivery room/operating room temperatures and thermal mattress use. Polyethylene bag use compliance was 50%.

IMPLICATIONS FOR PRACTICE

Golden Hour protocols have proven to be an effective tool. Thermoregulation is a significant component of these protocols, and it is imperative that every step is taken to manage the environmental temperature during the birth and admission process.

IMPLICATIONS FOR RESEARCH

There is a need for continued research on the impacts of thermoregulatory devices and protocols, with resulting practice and device recommendations.

A quality improvement initiative to reduce hypothermia in a Baby-Friendly nursery - our story of algorithms, K-cards, and Key cards

BACKGROUND

Baby-Friendly hospitals encourage rooming-in newborns with mothers. In our institution, we noticed increased incidence of hypothermia following Baby-Friendly designation. We aimed to reduce the incidence of hypothermia in the mother-baby-unit to <15% and to decrease the rate of isolated hypothermia admissions to the neonatal intensive care unit (NICU) by 20% over two years.

METHODS

After a retrospective review of newborns ≥35 weeks gestation in the mother-baby-unit with hypothermia, we implemented multiple interventions such as nursing education, hypothermia algorithm, Kamishibai cards, and Key cards.

RESULTS

Hypothermia incidence in the mother-baby-unit decreased from 20.9 to 14.5% (p < 0.001) and infants requiring NICU admission decreased by 71% (p < 0.001) following all interventions. Apart from nursing education, all interventions led to significant reductions in both outcomes from baseline.

CONCLUSION

Instituting a hypothermia algorithm and utilizing K-cards and Key cards reduces the incidence of hypothermia in the mother-baby-unit and NICU admissions for isolated hypothermia.

Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean

The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.

Perinatal quality improvement bundle to decrease hypothermia in extremely low birthweight infants with birth weight less than 1000 g: single-center experience over 6 years

Normothermia (36.5°C–37. 5°C) at the time of admission to the neonatal intensive care unit (NICU) in extremely low birthweight (ELBW) infants (birth weight <1000 g) is associated with decreased morbidity and mortality, decreased length of stay and hospital costs. We designed a thermoregulation bundle to decrease hypothermia (<36.5°C) in ELBW infants with a multidisciplinary perinatal quality improvement initiative that included the following key interventions: dedicated delivery room (DR)/operating room (OR) for all preterm deliveries of ≤32 weeks with DR/OR temperature set 24/7 at 74°F by the hospital engineering staff, use of exothermic mattress, preheated radiant warmer set at 100% for heat prior to delivery, servo-controlled mode after the neonate is placed on the warmer, and use of plastic wrap, head cap and warm towels. A total of 200 ELBW infants were admitted to our NICU between January 1, 2014 and December 31, 2019. Hypothermia (<36.5°C) occurred in 2.5% of infants, normothermia (36.5°C–37.5°C) in 91% of infants and transitional hyperthermia (>37.5°C) in 6.5% of ELBW infants. No case of moderate hypothermia (32°C–36°C) was seen in our infants. Our target rate of less than 10% hypothermia was reached in ELBW infants over the last 2 years with no cases of moderate hypothermia in 6 years. Eliminating hypothermia among ELBW remains a challenge and requires team effort and continuous quality improvement efforts.

Enhanced recovery after cesarean delivery: a challenge for anesthesiologists

Enhanced recovery after cesarean (ERAC) delivery is an evidence-based, multi-disciplinary approach throughout pre-, intra-, post-operative period. The ultimate goal of ERAC is to enhance recovery and improve the maternal and neonatal outcomes. This review highlights the role of anesthesiologist in ERAC protocols. This review provided a general introduction of ERAC including the purposes and the essential elements of ERAC protocols. The tool used for evaluating the quality of ERAC (ObsQoR-11) was discussed. The role of anesthesiologist in ERAC should cover the areas including management of peri-operative hypotension, prevention and treatment of intra- and post-operative nausea and vomiting, prevention of hypothermia and multi-modal peri-operative pain management, and active pre-operative management of unplanned conversion of labor analgesia to cesarean delivery anesthesia. Although some concerns still remain, ERAC implementation should not be delayed. Regular assessment and process improvement should be imbedded into the protocol. Further high-quality studies are warranted to demonstrate the effectiveness and efficacy of the ERAC protocol.

Delivery room handling of the newborn

For newly born babies, especially those in need of intervention at birth, actions taken during the first minute after birth, the so-called "Golden Minute", can have important implications for long-term outcomes. Both delivery room handling, including identification of maternal and infant risk factors and provision of effective resuscitation interventions, and antenatal care decisions regarding antenatal steroid administration and mode of delivery, are important and can affect outcomes. Anticipating risk factors for neonates at high risk of requiring resuscitation can decrease time to resuscitation and improve the prognosis. Following a review of maternal and fetal risk factors affecting newborn resuscitation, we summarize the current recommendations for delivery room handling of the newborn. This includes recommendations and rationale for the use of delayed cord clamping and cord milking, heart rate assessment [including the use of electrocardiogram (ECG) electrodes in the delivery room], role of suctioning in newborn resuscitation, and the impact of various ventilatory modes. Oxygenation should be monitored by pulse oximetry. Effects of oxygen and surfactant on subsequent pulmonary outcomes, and recommendations for provisions of appropriate thermoregulatory support are discussed. Regular teaching of delivery room handling should be mandatory.

Barriers and enablers to the implementation of perioperative hypothermia prevention practices from the perspectives of the multidisciplinary team: a qualitative study using the Theoretical Domains Framework

Purpose: Inadvertent perioperative hypothermia is a significant problem for surgical patients globally, and is associated with many detrimental side-effects. Despite the availability of rigorously developed international evidence-based guidelines for prevention, a high incidence of this complication persists. This qualitative study aims to identify and examine the domains which act as barriers and enablers to perioperative hypothermia prevention practices, from the perspectives of the key healthcare professionals involved with perioperative temperature management. Methods: A qualitative study employing semi-structured interviews was utilized. A purposive sample of key stakeholders involved in perioperative temperature management, including perioperative nurses, anesthetists, surgeons, and perioperative managers, were recruited via email. The interview guide was developed in reference to the Theoretical Domains Framework. All interviews were recorded, de-identified, transcribed, and coded. Belief statements were generated within each domain, and a frequency score generated for each belief. Finally, the domains were mapped to the COM-B model of the Behavior Change Wheel to develop recommendations for future interventions. Results: Twelve participants were included including eight nurses, two surgeons, and two anesthetists. Eleven key theoretical domains that influence the uptake of perioperative hypothermia practices were identified: knowledge; skills; social/professional role and identity; beliefs about capabilities; optimism; beliefs about consequences; reinforcement; goals; memory, attention, and decision processes; environmental context and resources; social influence. Suggested intervention strategies include training, reminder systems, audit, and feedback, organizational support to resolve lack of control of ambient temperature, as well as provision of accurate temperature measurement devices. Conclusion: Future interventions to address the key behavioral domains and improve perioperative hypothermia prevention need to be evaluated in the context of feasibility, effectiveness, safety, acceptability, and cost by the target users. All suggested intervention strategies need to take a team-based, multi-modal approach, as this is most likely to facilitate improvements in perioperative hypothermia prevention.

Antecedents and outcomes of hypothermia at admission to the neonatal intensive care unit

Objective: To evaluate the association between morbidities preceding and following neonatal intensive care unit (NICU) admission with hypothermia.Study design: NICU admission temperatures for 1271 infants admitted to the NICU at Tufts Medical Center (TMC) between 2012 and 2015 were compared to all Vermont Oxford Network (VON) centers in 2014. We analyzed demographic data, prevalence of hypothermia, and associations with prenatal and neonatal morbidities.Result: Prevalence of hypothermia at TMC was 19% compared to 25% in the VON. We found a significant association between hypothermia and maternal race, birth weight, gestational age, antenatal steroids, chorioamnionitis, mode of delivery, and Apgar scores.Conclusion: Continued emphasis should be placed on avoiding neonatal hypothermia during the first hours of postnatal life.

Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2)

The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care, with primarily a maternal focus. The "focused" pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider procedure from the decision to operate (starting with the 30-60 minutes before skin incision) through the surgery. The literature search (1966-2017) used Embase and PubMed to search medical subject headings including "cesarean section," "cesarean section," "cesarean section delivery," and all pre- and intraoperative Enhanced Recovery After Surgery items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system as used and described in previous Enhanced Recovery After Surgery Society guidelines. The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with Enhanced Recovery After Surgery-directed preoperative elements, intraoperative elements, and postoperative elements. Specifics of the intraoperative care included the use of prophylactic antibiotics before the cesarean delivery, appropriate patient warming intraoperatively, blunt expansion of the transverse uterine hysterotomy, skin closure with subcuticular sutures, and delayed cord clamping. A number of specific elements of intraoperative care of women who undergo cesarean delivery are recommended based on the evidence. The Enhanced Recovery After Surgery Society guideline for intraoperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for intraoperative care with primarily a maternal focus. When the cesarean delivery pathway (elements/processes) is studied, implemented, audited, evaluated, and optimized by maternity care teams, this will create an opportunity for the focused and optimized areas of care and recommendations to be further enhanced.

Effect of preheating on the maintenance of body temperature in surgical patients: a randomized clinical trial

Objective:

to evaluate the effect of preheating on the maintenance of body temperature of patients submitted to elective gynecological surgeries.

Method:

eighty-six patients were randomized, without blinding, to receive usual care (heating with a cotton sheet and blanket) or preheating with a forced air system for 20 minutes (38°C). All patients were actively heated during the intraoperative period. Data were collected from admission of the patient in the surgical center until the end of the surgery. Body temperature was measured during the preoperative and intraoperative periods with an infrared tympanic thermometer. A thermo-hygrometer was used to monitor air temperature and humidity of the operating room.

Results:

data indicated homogeneity between the groups investigated. There was no statistically significant difference between groups after preheating (p = 0.27). At the end of the surgery, the mean temperature of the groups studied was the same (36.8°C), with a statistically non-significant difference (p = 0.66).

Conclusion:

preheating with the heated forced air system had a similar effect to the usual care in the body temperature of patients submitted to elective gynecological surgeries. ClinicalTrials.gov n. NCT02422758. CAAE, n. 38320814.2.0000.5393.

Hipotermia e banho do recém-nascido nas primeiras horas de vida

Resumo OBJETIVO analisar a ocorrência de hipotermia em recém-nascidos antes e após o banho nas primeiras horas de vida. MÉTODO estudo transversal, no qual se verificou a temperatura axilar de recém-nascidos antes do banho, após o banho, 30 minutos após o banho e 60 minutos, no Centro Obstétrico. Na análise estatística utilizou-se os Testes Qui-Quadrado, t de Student e Mann-Whitney, com α = 0,05. RESULTADOS Foram incluídos 149 recém-nascidos no estudo, evidenciando-se a prevalência de hipotermia neonatal em 40,3% dos casos, tendo associação com significância estatística (p< 0,001) entre a ocorrência de hipotermia neonatal em todos os momentos de verificação de temperatura axilar. Constatou-se correlação estatística significativa entre as variáveis: temperatura da sala de parto e a verificação da temperatura 60 minutos após o banho (p= 0,032). CONCLUSÕES Conclui-se que o primeiro banho pode ser adiado para favorecer a adaptação do neonato ao ambiente extrauterino, prevenindo a ocorrência de hipotermia neonatal.

Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants

BACKGROUND

Newborn admission temperature is a strong predictor of outcomes across all gestations. Hypothermia immediately after birth remains a worldwide issue and, if prolonged, is associated with harm. Keeping preterm infants warm is difficult even when recommended routine thermal care guidelines are followed in the delivery room.

OBJECTIVES

To assess the efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room, compared with routine thermal care or any other single/combination of intervention(s) also designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5), MEDLINE via PubMed (1966 to 30 June 2016), Embase (1980 to 30 June 2016), and CINAHL (1982 to 30 June 2016). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Trials using randomised or quasi-randomised allocations to test interventions designed to prevent hypothermia (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery room for infants at < 37 weeks' gestation and/or birth weight ≤ 2500 grams.

DATA COLLECTION AND ANALYSIS

We used Cochrane Neonatal methods when performing data collection and analysis.

MAIN RESULTS

Twenty-five studies across 15 comparison groups met the inclusion criteria, categorised as: barriers to heat loss (18 studies); external heat sources (three studies); and combinations of interventions (four studies).Barriers to heat loss Plastic wrap or bag versus routine carePlastic wraps improved core body temperature on admission to the neonatal intensive care unit (NICU) or up to two hours after birth (mean difference (MD) 0.58°C, 95% confidence interval (CI) 0.50 to 0.66; 13 studies; 1633 infants), and fewer infants had hypothermia on admission to the NICU or up to two hours after birth (typical risk ratio (RR) 0.67, 95% CI 0.62 to 0.72; typical risk reduction (RD) -0.25, 95% CI -0.29 to -0.20; number needed to treat for an additional beneficial outcome (NNTB) 4, 95% CI 4 to 5; 10 studies; 1417 infants). Risk of hyperthermia on admission to the NICU or up to two hours after birth was increased in infants in the wrapped group (typical RR 3.91, 95% CI 2.05 to 7.44; typical RD 0.04, 95% CI 0.02 to 0.06; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 17 to 50; 12 studies; 1523 infants), but overall, fewer infants receiving plastic wrap were outside the normothermic range (typical RR 0.75, 95% CI 0.69 to 0.81; typical RD -0.20, 95% CI -0.26 to -0.15; NNTH 5, 95% CI 4 to 7; five studies; 1048 infants).Evidence was insufficient to suggest that plastic wraps or bags significantly reduce risk of death during hospital stay or other major morbidities, with the exception of reducing risk of pulmonary haemorrhage.Evidence of practices regarding permutations on this general approach is still emerging and has been based on the findings of only one or two small studies.External heat sourcesEvidence is emerging on the efficacy of external heat sources, including skin-to-skin care (SSC) versus routine care (one study; 31 infants) and thermal mattress versus routine care (two studies; 126 infants).SSC was shown to be effective in reducing risk of hypothermia when compared with conventional incubator care for infants with birth weight ≥ 1200 and ≤ 2199 grams (RR 0.09, 95% CI 0.01 to 0.64; RD -0.56, 95% CI -0.84 to -0.27; NNTB 2, 95% CI 1 to 4). Thermal (transwarmer) mattress significantly kept infants ≤ 1500 grams warmer (MD 0.65°C, 95% CI 0.36 to 0.94) and reduced the incidence of hypothermia on admission to the NICU, with no significant difference in hyperthermia risk.Combinations of interventionsTwo studies (77 infants) compared thermal mattresses versus plastic wraps or bags for infants at ≤ 28 weeks' gestation. Investigators reported no significant differences in core body temperature nor in the incidence of hypothermia, hyperthermia, or core body temperature outside the normothermic range on admission to the NICU.Two additional studies (119 infants) compared plastic bags and thermal mattresses versus plastic bags alone for infants at < 31 weeks' gestation. Meta-analysis of these two studies showed improvement in core body temperature on admission to the NICU or up to two hours after birth, but an increase in hyperthermia. Data show no significant difference in the risk of having a core body temperature outside the normothermic range on admission to the NICU nor in the risk of other reported morbidities.

AUTHORS' CONCLUSIONS

Evidence of moderate quality shows that use of plastic wraps or bags compared with routine care led to higher temperatures on admission to NICUs with less hypothermia, particularly for extremely preterm infants. Thermal mattresses and SSC also reduced hypothermia risk when compared with routine care, but findings are based on two or fewer small studies. Caution must be taken to avoid iatrogenic hyperthermia, particularly when multiple interventions are used simultaneously. Limited evidence suggests benefit and no evidence of harm for most short-term morbidity outcomes known to be associated with hypothermia, including major brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotising enterocolitis, and nosocomial infection. Many observational studies have shown increased mortality among preterm hypothermic infants compared with those who maintain normothermia, yet evidence is insufficient to suggest that these interventions reduce risk of in-hospital mortality across all comparison groups. Hypothermia may be a marker for illness and poorer outcomes by association rather than by causality. Limitations of this review include small numbers of identified studies; small sample sizes; and variations in methods and definitions used for hypothermia, hyperthermia, normothermia, routine care, and morbidity, along with lack of power to detect effects on morbidity and mortality across most comparison groups. Future studies should: be adequately powered to detect rarer outcomes; apply standardised morbidity definitions; focus on longer-term outcomes, particularly neurodevelopmental outcomes.