WARMING-UP TO NORMOTHERMIA Slide 1 Introduction: Happy Friday I am Kathleen Kelley, the nurse educator for Perioperative Services in the HR/PACU and a nurse practitioner. And welcome to “Warming up to Normothermia.” A Presentation from VUMC Perioperative Services Kathleen C. Kelley, MSN APRN BC August 20, 2010

'Warming Up to Normothermia' is designed for Perioperative staff  to understand and to maintain optimal surgical patient temperature This presentation reviews definitions, physiological outcomes of hypothermia, common causes of hypothermia and perioperative expectations Slide 2 This program is designed for the Perioperative staff to understand and to maintain optimal surgical patient temperature. We know that keeping patients at normal temperature throughout the perioperative period improves their outcome. Literature suggests that the higher the compliance in keeping the patient warm the better. Did you know that surgical patients with mild hypothermia had 3 times the likelihood of developing a surgical site infection?

Course Objectives To know the definition of Normothermia To know the VUMC Perioperative Goals for Surgical Patients To become familiar with Normothermia  terminology To identify Dangers of Hypothermia Slide 3 Due to the research on normothermia, Keeping our patient warm pre-operatively, intra-operatively and postoperatively is so very important that hospital reimbursement and SCIP performance measures have been based upon them. This presentation reviews definitions, physiological outcomes of hypothermia, common causes of hypothermia and perioperative expectations. We are in a position to achieve a performance level well beyond this SCIP measure. I am excited to be here today to make warm the norm! To be able to identify common risk factors &  causes of hypothermia To identify Perioperative Expectations To change practice- “Make Warm the Norm”

What is Normothermia? A core temperature range of 36°C to 38°C (98.6°F–100.4°F) Slide 4 So What is Normothermia? Normothermia is a core temperature range of 36°C to 38°C which is 98.6°F and 100.4°F

Medical Center Perioperative Goals For Surgical Patients: To provide the patient with a consistent approach for Normothermia while in the Perioperative setting unless the procedure necessitates a hypothermic environment Target Patient Temperature: 90% patients with first and post-op temp > 36°C 80% patients with minimum temp > 36°C Intra op Room Temperature Goals: OR Temperature  =  24°C (75° F)  Level 1 Trauma = 29.5°C  (85° F) Slide five The Vanderbilt medical Center preoperative goals are to provide the patient with a consistent approach for Normothermia while in the perioperative setting unless the procedure necessitates a hypothermic environment Target goals are that 90% of patients with the first and post-op temperature being greater than 36°C or 98.6 F and 80% with a minimum tech temperature greater than 36°C or 98.6 F And that a OR room temperature be at 24°C 75°F level I trauma to be 29.5°C 85°F

Terminology Core Temperature:  The thermal compartment of the body composed of highly perfused tissues where the temperature is uniform and high compared to the rest of the body Ambient Temperature: simply means "the temperature of the surroundings" Hypothermia: core temperature less than 36°C anytime during the Perioperative period Slide six So let’s review some terminology Core temperature is the thermal compartment of the body composed of highly perfused tissues where the temperature is uniform and high compared to the rest of the body. The core region is lungs ,heart and head Ambient temperature simply means the temperature of your surroundings. The temperature in the holding room. The temperature in the operating room The temperature in the PACU Hypothermia is simply the core temperature less than 36°C or 98.6 F anytime during the perioperative period.

Physiological effects of Mild Hypothermia Patient Temperature is 32–35°C or 90–95°F Shivering Cold diuresis Hypertension Mental confusion Tachycardia Hyperglycemia Tachypnea Hepatic Dysfunction Vasoconstriction Piloerection (goose bumps) Slide seven So what are the physiological effects of mild hypothermia? Shivering tachypnea mental confusion Hypertension vasoconstriction hyperglycemia tachycardia cold diuresis hepatic dysfunction goosebumps

Risks Factors for Hypothermia Extremes in patient ages Female sex, and physical status Ambient room temperatures Length and type of surgical procedure Amount of body fat (Cachexia -physical tissue wasting with loss of weight and muscle mass) Pre-existing conditions- (peripheral vascular disease, endocrine disease, pregnancy, burns, open wounds, etc.) Significant fluid shifts/Use of cold irrigates Use of general and regional anesthesia Induced inhibition of thermoregulation during surgical procedures Decreased metabolic heat production/Increased environmental heat loss Redistribution of heat within the body Slide eight So who is at risk for becoming cold? Infants, and elderly--Extremes in patient ages Female sex and physical status Ambient at room temperatures Length and type of surgical procedure Amount of body fat- cachexia is the physical tissue wasting with loss of weight and muscle mass Pre-existing conditions peripheral vascular disease and endocrine disease, pregnancy, burns (etc.) Significant fluid shifts/use of cold irrigates Use of general and regional anesthesia Induced inhibition of thermal regulation during surgical procedures Decrease metabolic heat production/ Increased environmental heat loss Redistribution of heat within the body

What are the Physiological Outcomes of Hypothermia? Slide nine So what are the adverse outcomes of being cold?

Surgical site infections Adverse cardiac events Discomfort Research suggests that patients who are hypothermic during the Perioperative phase of their care have an increased risk of developing the following: Surgical site infections Adverse cardiac events Discomfort Longer length of stay in the hospital More prone to bleeding during surgery  In randomized studies, efforts to maintain Normothermia: Reduced infectious complications by 50% Reduced ileus, Hospital LOS for infected and uninfected patients Reduced cardiac morbidity Reduced blood loss Barie, PS Surgical Site Infections: Epidemiology and Prevention. Surgical Infections. Vol 3, Suppl 2002;s9-s21Jeran, L. American Society of PeriAnesthesia Nurses Development Panel. Clinical Guidelines for the Prevention   of Unplanned Perioperative Hypothermia. Journal of PeriAnesthesia Nursing.Oct. 2001 Vol 16(5) pp305-314. Tryba, M. Lehan, J. et al. Does active warming of severely injured trauma patients influence perioperative morbidity? Anesthesiology, 1996;85:A283. Slide 10 Our patients are at risk in developing surgical site infections, adverse cardiac events, discomfort, longer life stay in the hospital and are more prone to bleeding during surgery. Keeping our patients warm cuts infection rates are 50%, reduces bowel obstruction, length of stay in the hospital for infection, cardiac deaths and blood loss

Increased Blood Loss Increases blood loss secondary to: Temperature induced coagulopathy (bleeding or clotting disorders) Altered and reduce platelet function Decreased activation of coagulation cascade Increased need for transfusion of red blood cells, platelets, and plasma Slide 11 Hypothermia increases blood loss due to temperature induced bleeding and clotting disorders Altars and reduces platelet function Decreases activation of coagulation Increases the need for transfusion of red blood cells, platelets and plasma Barie, PS Surgical Site Infections: Epidemiology and Prevention. Surgical Infections. Vol 3, Suppl 2002;s9-s21 Jeran, L. American Society of PeriAnesthesia Nurses Development Panel. Clinical Guidelines for the Prevention   of Unplanned Perioperative Hypothermia. Journal of PeriAnesthesia Nursing.Oct. 2001 Vol 16(5) pp305-314. Tryba, M. Lehan, J. et al. Does active warming of severely injured trauma patients influence perioperative morbidity? Anesthesiology, 1996;85:A283.

Increased Infection Increases susceptibility to infections: Decreased perfusion, altered phagocytic function and decreased antibiotic penetration Decreased cutaneous blood flow Directly impaired immune function (neutrophils less effective) Protein wasting and decreased collagen synthesis Slide 12 As I stated earlier hypothermia places our patients at risk for increased infection. A chilled patient has decreased perfusion. Altered the phagocytic function. Decreased antibiotic penetration. Impaired blood flow, immune system and causes protein wasting.

Other Potential Complications Increased risk for adverse cardiac events (Increases cardiac morbidity: Vasoconstriction, shivering, cardiac dysrhythmias) Increased oxygen consumption due to shivering (400% to 500%) Increased energy requirements related to the increase in oxygen consumption Increased need for postoperative mechanical ventilation Medication metabolism is reduced while duration of action is longer Slide 13 Additionally our patients are at risk for cardiac death. Increased oxygen consumption due to shivering. Increased energy requirements related to shivering. Increased need for mechanical ventilation Medication Metabolism is reduced because of hypothermia

Perioperative Expectations It is not uncommon for patients to be hypothermic upon arrival to the Holding Room or Post Anesthesia Care Unit (PACU). Unless hypothermia is indicated (i.e. CABG) intra-operatively, the goal for the Perioperative patient is to maintain NORMOTHERMIA! Measure patient core temperature – if < 36.6, turn on forced air warming via BAIR PAWS. If greater, can d/c forced air warming. Increase Ambient Room Temperature- Recommended AORN Practice Guidelines  20°-24°C or 68°-75°F. Slide 14 Our goal is to keep our patients warm preoperatively, intra-operatively and postoperatively Measurement and recording of patient temperatures are essential. If less than 36.6°c forced air warming via bear paws are indicated. If greater than 36.6 °C then forced air warming may be discontinued Recommended Ambient room temperature according to AORN practice guidelines are 20 ° to 24 ° C or 68° to 75°F

Hypothermia in the Holding Room In the Pre-Op/Holding Room, reasons for patient being hypothermia may be due to Nurse/Patient perception Nurses may assume that a patient knows if he or she is cold thru interview. The patient may not always be aware that they are hypothermic. Or, the Patient maybe unable to communicate (example-trauma pt) Slide 15 In the Pre-Op/Holding Room, reasons for patient being hypothermia may be due to Nurse/Patient perception Nurses may assume that a patient knows if he or she is cold thru interview. The patient may not always be aware that they are hypothermic. Or, the Patient maybe unable to communicate (example-trauma pt) This is an educational opportunity for nurse to inform the patient of the benefits of Normothermia. This is an educational opportunity for nurse to inform the patient of the benefits of Normothermia.

Pre-Operative Management Measure the patient's temperature on admission (Tympanic is the preferred method) All elective cases should have Bair Paws placed on the patient in holding room and forced warm air turned on to maintain temperature greater than 36.5°C at all times Identify patient risk factors for hypothermia (age, weight, overall health etc) Determine the patient's thermal comfort level Observe for symptoms of hypothermia (Shivering, piloerection [goose bumps} and/or cold extremities) Slide 16 The Pre-op/Holding Room nurse is responsible for: Placing on the bair paws Measuring the patient’s temperature on admission Identifying any risk factors for hypothermia Determining what the patient’s thermal comfort level is Observing for symptoms of hypothermia As a review, when checking adult tympanic temperature be sure to gently pull the ear and then back if the patient has a temp less than 36°C inform the anesthesia provider. Hold your patient’s head so it does not move, or tell the person not to move his head. If you are checking an adult, gently pull the ear up and then back.

Temperature Regulating Device Safety Device Safety for HR/PACU Plastic surfaces should not come in contact with patient’s skin. Unless temperature-regulating blankets are designed to be placed next to patient’s skin, a thin cloth covering should be placed between the device and the patient to protect the skin. Any heat-regulating device should be used according to manufacturer’s recommendations.  Skin integrity should be inspected before, periodically during (when possible), and after using devices such as ice packs and temperature-regulating blankets. Apply warm blankets per policy Adjust room temperature Monitor patient temperature to avoid overheating Use heat-maintaining devices (e.g., hats, blankets, socks) Administer warmed irrigation or infusion solutions Administer humidified oxygen and/or anesthetic gases  Fluids should be heated or cooled in devices intended for that purpose Microwaves and autoclaves should not be used as warming devices Slide 17 In review plastic surfaces should never come into contact with the patient’s skin when the warming device is on. Apply cloth covering between the device and the patient to protect the skin. Apply warming blankets per policy. Adjust room temperature. Monitor patient temperature to avoid overheating Using heat maintaining devices such as blankets and socks Administer warm irrigation or infusion solutions Administered humidified oxygen Fluids should be heated or cooled in devices intended for that purpose No microwave or autoclave should be used as warming devices.

Slide 18 Here is the Celsius Fahrenheit conversion calculator on the beacons charting The Celsius/Fahrenheit Conversion Calculator can be found in the electronic VPIMS charting (Pre-Op, Intra-Op and Post-Op)

Intra Operative Causes Hypothermia In the Intra-Operative/OR areas, hypothermia may be due to : Low ambient temperature in the operating room Administration of un-warmed IV fluids Decreased metabolic rate during surgery Medication-induced vasodilation Exposure of body cavities to room-temperature air Loss of heat from lungs when un-warmed Inhaled gases are used Use of general anesthesia Slide 19 Common causes of hypothermia in the OR Low ambient temperature in the operating room Administration of unwarned IV fluids Decreased metabolic rate during surgery Medication-induced vasodilation Exposure of body cavities to room-temperature air Loss of heat from lungs when un-warmed Inhaled gases are used Use of general anesthesia

Intra-Op Management Room temperature to be recorded in  VPIMS. Recommended ambient room temperature-20°-24°C or 68°-75°F Anesthesia records temperatures during case and "30 minutes prior to or 15 minutes after anesthesia end time” in Gas Chart. Room temperature may be adjusted during case as long as the patient core temp  > 36.5°C Peri-induction and intra-operative management: Bear Paws (if elective) / Bear Hugger applied, forced air @ 40°C prior to induction & prep Upper & lower forced air warming devices should be applied as allowed by the case Intra-operative fluids and irrigation should be warmed to 37°C per fluid warmer Should cover the lower body with Bear Hugger prior to prep to avoid air turbulence over the prep Drape patient prior to turning on the upper body warmer to prevent air turbulence Forced air devices should be utilized during induction of general anesthesia, held for prep of patient, but reinitiated as soon as draping is completed Patient exposure should be minimized as much as possible during and after induction Slide 20 The OR nurse is responsible for: Room temperature to be recorded in  VPIMS. Recommended ambient room temperature-20°-24°C or 68°-75°F Note: that Anesthesia records temperatures during case and "30 minutes prior to or 15 minutes after anesthesia end time” in Gas Chart. Room temperature may be adjusted during case as long as the patient core temp  > 36.5°C Peri-induction and intra-operative management: Bear Paws (if elective) / Bear Hugger applied, forced air @ 40°C prior to induction & prep Upper & lower forced air warming devices should be applied as allowed by the case Intra-operative fluids and irrigation should be warmed to 37°C per fluid warmer Should cover the lower body with Bear Hugger prior to prep to avoid air turbulence over the prep Drape patient prior to turning on the upper body warmer to prevent air turbulence Forced air devices should be utilized during induction of general anesthesia, held for prep of patient, but reinitiated as soon as draping is completed Patient exposure should be minimized as much as possible during and after induction

Slide 21 OR Ambient Temp- 24 degrees C 75 degrees F Level 1 Trauma-29.5 degrees C 85 degrees F

Temperature Regulating Device Safety Device Safety for Intra-OP Plastic surfaces should not come in contact with patient’s skin. Unless temperature-regulating blankets are designed to be placed next to patient’s skin, a thin cloth covering should be placed between the device and the patient to protect the skin. Any heat-regulating device should be used according to manufacturer’s recommendations.  Skin integrity should be inspected before, periodically during (when possible), and after using devices such as ice packs and temperature-regulating blankets. Apply warm blankets per policy Limit amount of skin surface exposed during positioning and skin preparation  Limit amount of time between skin preparation and draping Prevent surgical drapes from becoming wet Adjust room temperature Monitor patient temperature to avoid overheating Use heat-maintaining devices (e.g., hats, blankets, socks) Administer warmed irrigation or infusion solutions Administer humidified oxygen and/or anesthetic gases  Fluids should be heated or cooled in devices intended for that purpose Microwaves and autoclaves should not be used as warming devices. Slide 22 Again plastic surfaces should never come into contact with the patient’s skin when the warming device is on. Apply cloth covering between the device and the patient to protect the skin. Apply warming blankets per policy. OR Specific: Limit amount of skin surface exposed during positioning and skin preparation  Limit amount of time between skin preparation and draping Prevent surgical drapes from becoming wet Adjust room temperature. Monitor patient temperature to avoid overheating Using heat maintaining devices such as blankets and socks Administer warm irrigation or infusion solutions Administered humidified oxygen Fluids should be heated or cooled in devices intended for that purpose No microwave or autoclave should be used as warming devices.

Post-Operative Management In the PACU, Hypothermia may be due to the failure to recognize warming device is not connected or the inadvertent removal of the warming device during transfer from the OR bed to the stretcher. Slide 23 In the PACU, Hypothermia may be due to the failure to recognize warming device is not connected or the inadvertent removal of the warming device during transfer from the OR bed to the stretcher.

Post-operative management: Patients are immediately covered with either warm blankets and/or forced air device depending on patient core temperature Initial patient temperature is taken on ALL PACU patients Nurses are to contact Anesthesia Provider or Attending Physician if patient core temperature is < 36°C Increase ambient room temperature (minimum 24°C or 75°F) Warm fluids: Intravenous Humidify and warm gases on ventilator patient (38°C-40°C) Assess temperature and patient’s thermal comfort level every 30 minutes until Normothermia is reached Measure and record temperatures thru out PACU care and prior to discharge Slide 24 Post-operative management: Patients are immediately covered with either warm blankets and/or forced air device depending on patient core temperature Initial patient temperature is taken on ALL PACU patients Nurses are to contact Anesthesia Provider or Attending Physician if patient core temperature is < 36°C Increase ambient room temperature (minimum 24°C or 75°F) Warm fluids: Intravenous Humidify and warm gases on ventilator patient (38°C-40°C) Assess temperature and patient’s thermal comfort level every 30 minutes until Normothermia is reached Measure and record temperatures thru out PACU care and prior to discharge

Intra Operative Recommendations for Providers Intra-operative, ambient room temperature for Non-trauma cases should be set at 24°C (75°F) Level 1 Trauma 29.5°C (85°F) Slide 25 Intra Operative Recommendations for ProvidersIntra-operative, ambient room temperature for Non-trauma cases should be set at 24°C (75°F) Level 1 Trauma 29.5°C (85°F)

Anesthesia records temperatures during case and "30 minutes prior to or 15 minutes after anesthesia end time” in Gas Chart-vitals grid as shown below Slide 26 Anesthesia records temperatures during case and "30 minutes prior to or 15 minutes after anesthesia end time” in Gas Chart-vitals grid as shown below

The second temperature is charted under the Emergence Tab in the PACU Vital Sign section. Slide 26 The second temperature is charted under the Emergence Tab in the PACU Vital Sign section.

Where We Stand with Hypothermia? Slide 28 Where We Stand with Hypothermia?

The graph demonstrates the percentage of patients' Slide 29 The graph demonstrates the percentage of patients' temperatures < 36°C by Service We are in a position to achieve a performance level well beyond this SCIP measure but we must all be committed to make Warm the Norm! Opportunity to improve and surpass the SCIP measure The graph demonstrates the percentage of patients' temperatures < 36°C by Service

The Bottom-Line on Normothermia Patient exposure should be minimized as much as possible during and after induction Forced air devices should be utilized during induction of general anesthesia, held for prep, but reinitiated as soon as draping is completed Normothermia: Reduces the negative effects experienced by the patient Optimizes wound healing and recovery times Prevents extended hospitalization, thereby reducing cost of care and increasing patient satisfaction The Bottom-Line on Normothermia Slide 30 Patient exposure should be minimized as much as possible during and after induction Forced air devices should be utilized during induction of general anesthesia, held for prep, but reinitiated as soon as draping is completed Normothermia Reduces the negative effects experienced by the patient Optimizes wound healing and recovery times Prevents extended hospitalization, thereby reducing cost of care and increasing patient satisfaction

A Presentation from VUMC Perioperative Services Questions? Thank you for your time and the opportunity in sharing this information on Normothermia! And Remember…..Make Warm the Norm! Slide 31 Thank you for your time and the opportunity in sharing this information on Normothermia! And Remember…..Make Warm the Norm! A Presentation from VUMC Perioperative Services

MAKE WARM THE NORM! Slide 32 This is Norm This is Norm