1. 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

2. '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?

3. 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”

4. 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

5. 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

6. 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.

7. 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

8. 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

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

10. 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 Vol 16(5) pp 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

11. 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 Vol 16(5) pp Tryba, M. Lehan, J. et al. Does active warming of severely injured trauma patients influence perioperative morbidity? Anesthesiology, 1996;85:A283.

12. 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.

13. 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

14. 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

15. 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.

16. 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.

17. 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.

18. 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)

19. 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

20. 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 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 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

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

22. 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.

23. 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.

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
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

25. 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)

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
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

27. 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.

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

29. 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

30. 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

31. 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

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