Effect of a thermal care bundle on the prevention, detection and treatment of perioperative inadvertent hypothermia

Barriers and facilitators to evidence-based perioperative hypothermia management for orthopaedic patients: A systematic review

AIM

To assess barriers and facilitators to the implementation of guidelines for the prevention of inadvertent perioperative hypothermia in orthopaedic patients.

DESIGN

Systematic review.

DATA SOURCES

Nine databases: PubMed, Embase, CINAHL, Cochrane CENTRAL, PsycINFO, ProQuest Dissertations and Theses, Scopus, Web of Science and Trip Clinical Evidence Database.

METHODS

Primary studies published in English between January 2008 to July 2022 were screened. Study selection, quality assessment, and data extraction were completed independently by researchers. Data were extracted using the Consolidated Framework for Implementation Research and mapped to the Expert Recommendations for Implementing Change strategies.

RESULTS

Eighty-seven studies were included in the review. The most frequently reported barriers and facilitators related to evidence strength, relative advantage, and cost of implementing perioperative hypothermia prevention guidelines. The top four ERIC strategies were: Identify and prepare champions; Conduct educational meetings; Assess for readiness and identify barriers and facilitators; and Inform local opinion leaders.

CONCLUSION

This review provides synthesized evidence regarding barriers and facilitators to perioperative hypothermia guidelines for patients undergoing orthopaedic surgery.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Our work provides theory guided strategies to promote implementation of perioperative hypothermia prevention to assist nurses caring for patients undergoing orthopaedic surgery.

IMPACT

Findings provide professionals caring for patients undergoing orthopaedic surgery with theory-informed strategies to improve perioperative hypothermia prevention. Reducing perioperative hypothermia will improve outcomes for patients undergoing orthopaedic surgery.

REPORTING METHOD

The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020.

NO PATIENT OR PUBLIC CONSULTATION

Due to the study design, no patient or public consultation took place.

The Effect of Prewarming on Perioperative Hypothermia: A Systematic Review and Meta-analysis of Randomized Controlled Studies

PURPOSE

One of the methods for maintaining perioperative normothermia is prewarming. This study was conducted to investigate the effect of a preoperative prewarming intervention on perioperative body temperature.

DESIGN

Systematic review and meta-analysis.

METHODS

A literature review was conducted using PubMed, CINAHL, Cochrane Central, Science Direct, Springer Link, Scopus, Web of Science, and Ovid databases. Randomized controlled trials that investigate the effect of prewarming on body temperature in the prevention of perioperative hypothermia were included. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Methodological quality was assessed using the Cochrane Collaboration "risk of bias" tool. Meta-analysis was performed with Comprehensive Meta-Analysis, version 2. Moderator analysis and publication bias assessment were performed. Funnel plots were analyzed using Orwin's fail-safe N, Trim, and Fill test method to investigate the source of heterogeneity.

FINDINGS

A total of 907 studies were found. The systematic review included 27 studies. Of these, 23 were included in the intraoperative meta-analysis, and 16 were included in the postoperative meta-analysis. According to the meta-analysis results, the prewarming intervention was effective in maintaining normothermia in the intraoperative (Hedge's g = 0.972, 95% confidence intervaI = 0.674 to 1.270) and postoperative (Hedge's g = 0.818, 95% confidence intervaI = 0.520 to 1.114) periods.

CONCLUSIONS

The findings of this systematic review and meta-analysis showed that preoperative prewarming played a significant role in providing and maintaining perioperative normothermia.

Effects of Perioperative Hypothermia on Extubation, Recovery Time, and Postoperative Shivering in Breast Surgery

Women undergoing breast surgery seem to be under the risk for hypothermia (central body temperature <36°) due to the uncertainty caused by the preoperative preparation time and the variety of operations, leading to neglect of warming precautions. The study examines the perioperative hypothermia (PH) in breast surgery and the relationships between the depth of decrease in body temperature and individual or clinical variables. This prospective, cross-sectional, observational study includes 120 female patients 18-65 years of age who were given general anesthesia for breast surgery. The incidence of hypothermia was 68.1%. The given patients were discriminated as body temperature <36°, hypothermia was significantly related with lower weight, body mass index, American Society of Anesthesiology (ASA) score, baseline body temperatures, higher extubation, and recovery times. When patients' temperature decreases by >1 or 1.5°, lower age and longer durations of operation and anesthesia were also significant variables. The incidence of shivering is quite high at temperatures below 36°C or at 1 and 1.5°C reductions from baseline (72.7%, 84%, 94.1%, respectively). Body temperature changes of the patients had no effect on nausea-vomiting and pain scores. It turned out that the incidence of PH and shivering is high in women who underwent breast surgery. We think that the depth of decrease in body temperature should be taken into account when evaluating the predictors or clinical consequences of hypothermia, except for the 36°C limit for body temperature.

Perioperative hypothermia prevention: development of simple principles and practice recommendations using a multidisciplinary consensus-based approach

OBJECTIVES

To develop a consensus on evidence-based principles and recommendations for perioperative hypothermia prevention in the Australian context.

DESIGN

This study was informed by CAN-IMPLEMENT using the ADAPTE process: (1) formation of a multidisciplinary development team; (2) systematic search process identifying existing guidance for perioperative hypothermia prevention; (3) appraisal using the AGREE II Rigor of Development domain; (4) extraction of recommendations from guidelines meeting a quality threshold using the AGREE-REX tool; (5) review of draft principles and recommendations by multidisciplinary clinicians nationally and (6) subsequent round of discussion, drafting, reflection and revision by the original panel member team.

SETTING

Australian perioperative departments.

PARTICIPANTS

Registered nurses, anaesthetists, surgeons and anaesthetic allied health practitioners.

RESULTS

A total of 23 papers (12 guidelines, 6 evidence summaries, 3 standards, 1 best practice sheet and 1 evidence-based bundle) formed the evidence base. After evidence synthesis and development of draft recommendations, 219 perioperative clinicians provided feedback. Following refinement, three simple principles for perioperative hypothermia prevention were developed with supporting practice recommendations: (1) actively monitor core temperature for all patients at all times; (2) warm actively to keep body temperature above 36°C and patients comfortable and (3) minimise exposure to cold at all stages of perioperative care.

CONCLUSION

This consensus process has generated principles and practice recommendations for hypothermia prevention that are ready for implementation with local adaptation. Further evaluation will be undertaken in a large-scale implementation trial across Australian hospitals.

Perioperative temperature monitoring for patient safety: A period prevalence study of five hospitals

BACKGROUND

Monitoring body temperature is essential for safe perioperative care. Without patient monitoring during each surgical phase, alterations in core body temperature will not be recognised, prevented, or treated. Safe use of warming interventions also depends on monitoring. Yet there has been limited evaluation of temperature monitoring practices as the primary endpoint.

OBJECTIVE

To investigate temperature monitoring practices during all stages of perioperative care. We examined what patient characteristics are associated with the rate of temperature monitoring, along with clinical variables such as warming intervention or exposure to hypothermia.

DESIGN

An observational period-prevalence study over seven days across five Australian hospitals.

SETTINGS

Four metropolitan, tertiary hospitals and one regional hospital.

PARTICIPANTS

We selected all adult patients (N = 1690) undergoing any surgical procedure and any mode of anaesthesia during the study period.

METHODS

Patient characteristics, perioperative temperature data, warming interventions and exposure to hypothermia were retrospectively collected from patient charts. We describe the frequencies and distribution of temperature data at each perioperative stage, including adherence to minimum temperature monitoring based on clinical guidelines. To examine associations with clinical variables, we also modelled the rate of temperature monitoring using each patient's count of recorded temperature measurements within their calculated time interval from anaesthetic induction to postanaesthetic care unit discharge. All analyses adjusted 95% confidence intervals (CI) for patient clustering by hospital.

RESULTS

There were low levels of temperature monitoring, with most temperature data clustered around admission to postanaesthetic care. Over half of patients (51.8%) had two or less temperatures recorded during perioperative care and one-third (32.7%) had no temperature data at all prior to admission to postanaesthetic care. Of all patients that received active warming intervention during surgery, over two-thirds (68.5%) had no temperature monitoring recorded. In our adjusted model, associations between clinical variables and the rate of temperature monitoring often did not reflect clinical risk or need: rates were decreased for those with greatest operative risk (American Society of Anesthesiologists Classification IV: rate ratio (RR) 0.78, 95% CI 0.68-0.89; emergency surgery: RR 0.89, 0.80-0.98), and neither warming interventions (intraoperative warming: RR 1.01, 0.93-1.10; postanaesthetic care unit warming: RR 1.02, 0.98-1.07) nor hypothermia at postanaesthetic care unit admission (RR 1.12, 0.98-1.28) were associated with monitoring rate.

CONCLUSIONS

Our findings point to the need for systems-level change to enable proactive temperature monitoring over all phases of perioperative care to enhance patient safety outcomes.

REGISTRATION

Not a clinical trial.

Mapeamento cruzado das intervenções aplicadas ao diagnóstico de enfermagem: risco de hipotermia perioperatória

Objetivo: Mapear e validar as intervenções/atividades aplicadas ao paciente com diagnóstico de enfermagem de risco de hipotermia perioperatória. Método: Trata-se de estudo metodológico, com foco na construção e na validação de atividades/intervenções de enfermagem específicas para o diagnóstico de risco de hipotermia perioperatória da NANDA-I, realizado de agosto de 2020 a setembro de 2021. O processo envolveu três etapas: levantamento das atividades na literatura, mapeamento cruzado com as intervenções/atividades da Classificação das intervenções de enfermagem (NIC) e validação por especialistas, considerando válidos os itens com índice de validade de conteúdo>0,79. Resultados: Na revisão de literatura, foram elencados 12 artigos, que geraram 57 atividades, agrupadas em métodos ativos e passivos de aquecimento, além de medidas de monitoramento; em relação às intervenções de enfermagem, na NIC, foram mapeadas 3 intervenções, englobando 96 atividades. Por meio do mapeamento cruzado, foi possível construir 17 atividades de enfermagem a serem propostas para o perioperatório, sendo 15 validadas pelos 8 especialistas. Conclusão: Foram mapeadas e validadas 15 intervenções/atividades advindas do diagnóstico risco de hipotermia para serem desenvolvidas no período perioperatório, a fim de favorecer a qualidade assistencial.

Perioperative hypothermia in open and laparoscopic colorectal surgery

BACKGROUND

The consequences of even mild inadvertent perioperative hypothermia (IPH) are significant. There is a perception laparoscopic abdominal surgery is less prone to cause hypothermia than open surgery. However, during laparoscopic surgery, the peritoneal cavity is insufflated with carbon dioxide, which has a greater evaporative capacity than ambient air. This study compared the intra-operative temperature profile of patients undergoing open and laparoscopic colorectal surgery to define the incidence and severity of hypothermia.

METHODS

All adult patients undergoing colorectal surgery between May 2005 and August 2013 were identified from an electronic database. Cases were categorized into laparoscopic and open cases. Hypothermic episodes were defined as a temperature less than 36°C lasting for more than two consecutive minutes. The incidence of hypothermic episodes, the total time under 36°C and the area under the curve (degree-minutes) were calculated.

RESULTS

A total of 1547 cases were analysed. The overall incidence of hypothermia was 67.0%. The incidence of cases with a hypothermic episode was greater in the laparoscopic group compared to the open group (71.23% versus 63.16%; chi-squared P-value 0.001). However, when other factors were considered, there was no significant difference in the relative risk of a hypothermic episode between types of surgery. There were significant differences in the severity of hypothermia.

CONCLUSION

Despite current measures to reduce the incidence, IPH remains a significant problem in colorectal surgery irrespective of the surgical approach. Further research is required to better characterize techniques that can reduce its incidence.

The effects of active warming on perioperative inadvertent hypothermia in patients undergoing vitreoretinal surgery under local anesthesia

Purpose:

Perioperative inadvertent hypothermia (PIH) is the decrease in core temperature below 36°C. We aimed to assess whether PIH develops in patients operated under local anesthesia (ULA) for vitreoretinal surgery in the operating room and investigate active warming efficacy.

Methods:

Seventy-two patients were divided into two groups: Group 1 contained unwarmed patients (n = 36), and Group 2, warmed patients (n = 36). The core temperatures, heart rate (HR), and mean arterial pressure (MAP) of the patients were measured at the beginning of surgery, after 20 min, 40 min, 1 h, at the end of the operation, and during the postoperative period.

Results:

PIH incidence was 44.6% in Group 1, whereas no hypothermia was observed in Group 2. Patient temperatures at 20 min (P = 0.001), 40 min (P < 0.001), 1 h (P < 0.001), the end of the operation (P < 0.001), and the postoperative period (P < 0.001) were significantly higher in Group 2 than in Group 1. Patient HRs at the end of the operation and during the postoperative period were significantly lower in Group 2 (P = 0.005) than in Group 1 (P < 0.001). The intraoperative 40^th (P = 0.044) and 60^th (P < 0.001) minutes, end of operation (P < 0.001), and postoperative MAP (P < 0.001) values of Group 1 were significantly higher than those of Group 2.

Conclusion:

PIH may develop in patients operated ULA, especially with a low ambient temperature. Actively warming may help prevent the harmful effects of PIH.

Decreased incidence of perioperative inadvertent hypothermia and faster anesthesia recovery with increased environmental temperature: A nonrandomized controlled study

OBJECTIVE

To determine perioperative inadvertent hypothermia (PIH) incidence, risk factors, prevention methods, and effect of PIH prevention on anesthesia recovery times.

STUDY DESIGN

Nonrandomized controlled before-and-after trial.

ANIMALS

Dogs (n = 277) and cats (n = 20) undergoing open surgery.

METHODS

Incidence and risk factors for PIH (core temperature <96.8°F), existing thermal care practices, and recovery times were documented at baseline. For group 1, a thermal care bundle consisting of protocol-driven active warming combined with raised environmental temperatures (75°F) in induction rooms (IR) and operating rooms (OR) was implemented. Perioperative inadvertent hypothermia incidence and recovery times were recorded. For group 2, baseline active warming practices were resumed while environmental temperatures remained elevated.

RESULTS

Perioperative inadvertent hypothermia was associated with preoperative imaging (P = .039) and percentage clip area (P = .037). Perioperative inadvertent hypothermia decreased in group 1 (13.5%, n = 96, P < .001) and group 2 (13.0%, n = 100, P < .001) compared with baseline (35.6%, n = 101). Median time from anesthesia withdrawal to extubation decreased in group 1 (5 minutes, P = .028) and group 2 (5 minutes, P = .018) compared with baseline (7 minutes). Median time from anesthesia recovery to spontaneous food intake decreased in group 1 (6 hours, n = 92, P = .016) but not in group 2 (6.0 hours, n = 88, P = .060) compared with baseline (n = 94, 6.7 hours). No group differences in PIH risk factors were identified.

CONCLUSION

Perioperative inadvertent hypothermia incidence was high but reducible by raising environmental temperatures alone or in combination with increased focus on active warming. Reductions in PIH shortened recovery times.

CLINICAL SIGNIFICANCE

Maintaining IR and OR temperatures at the standard-of-care for human pediatric surgery reduces PIH and may improve outcomes.